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Bartolo M, Castelli A, Calabrese M, Buttacchio G, Zucchella C, Tamburin S, Fontana A, Copetti M, Fasano A, Intiso D. A wearable system for visual cueing gait rehabilitation in Parkinson's disease: a randomized non-inferiority trial. Eur J Phys Rehabil Med 2024; 60:245-256. [PMID: 38483335 PMCID: PMC11114153 DOI: 10.23736/s1973-9087.24.08381-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 01/30/2024] [Accepted: 02/19/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Gait disturbances represent one of the most disabling features of Parkinson's disease (PD). AIM The aim of this study was to evaluate the non-inferiority of a new wearable visual cueing system (Q-Walk) for gait rehabilitation in PD subjects, compared to traditional visual cues (stripes on the floor). DESIGN Open-label, monocentric, randomized controlled non-inferiority trial. SETTING Outpatients. POPULATION Patients affected by idiopathic PD without cognitive impairment, Hoehn and Yahr stage II-IV, Unified Parkinson's Disease Rating Scale motor section III ≥2, stable drug usage since at least 3 weeks. METHODS At the enrollment (T0), all subjects underwent a clinical/functional evaluation and the instrumental gait and postural analysis; then they were randomly assigned to the Study Group (SG) or Control Group (CG). Rehabilitation program consisted in 10 consecutive individual sessions (5 sessions/week for 2 consecutive weeks). Each session included 60 minutes of conventional physiotherapy plus 30 minutes of gait training by Q-Walk (SG) or by traditional visual cues (CG). Follow-up visits were scheduled at the end of the treatment (T1) and after 3 months (T2). RESULTS Fifty-two subjects were enrolled in the study, 26 in each group. The within-groups analysis showed a significant improvement in clinical scales and instrumental data at T1 and at T2, compared to baseline, in both groups. According to the between-group analysis, Q-Walk cueing system was not-inferior to the traditional cues for gait rehabilitation. The satisfaction questionnaire revealed that most subjects described the Q-Walk cueing system as simple, motivating and easily usable, possibly suitable for home use. CONCLUSIONS Data showed that motor rehabilitation of PD subjects performed by means of the new wearable Q-Walk cueing system was feasible and as effective as traditional cues in improving gait parameters and balance. CLINICAL REHABILITATION IMPACT Wearable devices can act as an additional rehabilitation strategy for long-term and continuous care, allowing patients to train intensively and extensively in household settings, favoring a tailor-made and personalized approach as well as remote monitoring.
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Affiliation(s)
- Michelangelo Bartolo
- Neurorehabilitation Unit, Rehabilitation Department, HABILITA Zingonia, Zingonia, Bergamo, Italy -
| | - Alberto Castelli
- Neurorehabilitation Unit, Rehabilitation Department, HABILITA Zingonia, Zingonia, Bergamo, Italy
| | - Marzia Calabrese
- Neurorehabilitation Unit, Rehabilitation Department, HABILITA Zingonia, Zingonia, Bergamo, Italy
| | - Giampiero Buttacchio
- Neurorehabilitation Unit, Rehabilitation Department, HABILITA Zingonia, Zingonia, Bergamo, Italy
| | | | - Stefano Tamburin
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Andrea Fontana
- Unit of Biostatistics, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | - Massimiliano Copetti
- Unit of Biostatistics, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, Toronto, ON, Canada
- Division of Neurology, University of Toronto, Toronto, ON, Canada
- Krembil Brain Institute, Toronto, ON, Canada
- Department of Parkinson's Disease and Movement Disorders Rehabilitation, Moriggia-Pelascini Hospital, Gravedona ed Uniti, Como, Italy
| | - Domenico Intiso
- Unit of Neurorehabilitation and Rehabilitation Medicine, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy
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Li Y, Zheng JJ, Wu X, Gao W, Liu CJ. Postural control of Parkinson's disease: A visualized analysis based on Citespace knowledge graph. Front Aging Neurosci 2023; 15:1136177. [PMID: 37032828 PMCID: PMC10080997 DOI: 10.3389/fnagi.2023.1136177] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 03/02/2023] [Indexed: 04/11/2023] Open
Abstract
Postural control impairment is one of the primary motor symptoms in patients with Parkinson's disease, leading to an increased risk of falling. Several studies have been conducted on postural control disorders in Parkinson's disease patients, but no relevant bibliometric analysis has been found. In this paper, the Web of Science Core Collection database was searched for 1,295 relevant papers on postural control in Parkinson's disease patients from December 2011 to December 2021. Based on the Citespace knowledge graph, these relevant papers over the last decade were analyzed from the perspectives of annual publication volume, countries and institutes cooperation, authors cooperation, dual-map overlay of journals, co-citation literature, and keywords. The purpose of this study was to explore the current research status, research hotspots, and frontiers in this field, and to provide a reference for further promoting the research on postural control in Parkinson's disease patients.
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Affiliation(s)
- Yan Li
- Department of Rehabilitation Medicine, Huadong Hospital, Fudan University, Shanghai, China
- Department of Sport Rehabilitation, Shanghai University of Sport, Shanghai, China
| | - Jie-Jiao Zheng
- Department of Rehabilitation Medicine, Huadong Hospital, Fudan University, Shanghai, China
- Department of Sport Rehabilitation, Shanghai University of Sport, Shanghai, China
- Shanghai Clinical Research Center for Rehabilitation Medicine, Shanghai, China
- *Correspondence: Jie-Jiao Zheng,
| | - Xie Wu
- Department of Sport Rehabilitation, Shanghai University of Sport, Shanghai, China
| | - Wen Gao
- Department of Rehabilitation Medicine, Huadong Hospital, Fudan University, Shanghai, China
- Shanghai Clinical Research Center for Rehabilitation Medicine, Shanghai, China
| | - Chan-Jing Liu
- Department of Sport Rehabilitation, Shanghai University of Sport, Shanghai, China
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Steinbach MJ, Campbell RW, DeVore BB, Harrison DW. Laterality in Parkinson's disease: A neuropsychological review. APPLIED NEUROPSYCHOLOGY. ADULT 2023; 30:126-140. [PMID: 33844619 DOI: 10.1080/23279095.2021.1907392] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Laterality of motor symptom onset in Parkinson's disease is both well-known and under-appreciated. Treatment of disorders that have asymmetric pathological features, such as stroke and epilepsy, demonstrate the importance of incorporating hemispheric lateralization and specialization into therapy and care planning. These practices could theoretically extend to Parkinson's disease, providing increased diagnostic accuracy and improved treatment outcomes. Additionally, while motor symptoms have generally received the majority of attention, non-motor features (e.g., autonomic dysfunction) also decrease quality of life and are influenced by asymmetrical neurodegeneration. Due to the laterality of cognitive and behavioral processes in the two brain hemispheres, analysis of hemibody side of onset can potentially give insight into expected symptom profile of the patient and allow for increased predictive accuracy of disease progression and outcome, thus opening the door to personalized and improved therapy in treating Parkinson's disease patients. This review discusses motor and non-motor symptoms (namely autonomic, sensory, emotional, and cognitive dysfunction) of Parkinson's disease in respect to hemispheric lateralization from a theoretical perspective in hopes of providing a framework for future research and personalized treatment.
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da Conceição NR, de Souza CR, Júlia ÁDO, de Lima-Pardini AC, Silva-Batista C, Teixeira LA, Coelho DB. Between-leg asymmetry in automatic postural responses to stance perturbations in people with Parkinson's disease. Gait Posture 2022; 97:40-42. [PMID: 35872481 DOI: 10.1016/j.gaitpost.2022.07.232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 07/11/2022] [Accepted: 07/17/2022] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Núbia Ribeiro da Conceição
- Human Motor Systems Laboratory, School of Physical Education and Sport, University of São Paulo, São Paulo, Brazil
| | - Caroline Ribeiro de Souza
- Human Motor Systems Laboratory, School of Physical Education and Sport, University of São Paulo, São Paulo, Brazil
| | - Ávila de Oliveira Júlia
- Human Motor Systems Laboratory, School of Physical Education and Sport, University of São Paulo, São Paulo, Brazil
| | | | - Carla Silva-Batista
- Exercise Neuroscience Research Group, School of Arts, Sciences, and Humanities, University of São Paulo, São Paulo, Brazil
| | - Luis Augusto Teixeira
- Human Motor Systems Laboratory, School of Physical Education and Sport, University of São Paulo, São Paulo, Brazil
| | - Daniel Boari Coelho
- Human Motor Systems Laboratory, School of Physical Education and Sport, University of São Paulo, São Paulo, Brazil; Biomedical Engineering, Federal University of ABC, São Bernardo do Campo, São Paulo, Brazil.
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Eldeeb HM, Abdelraheem HS. Functional gait assessment in early and advanced Parkinson’s disease. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2021. [DOI: 10.1186/s41983-021-00399-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Postural instability and balance problems in patients with Parkinson’s disease (PD) can seriously affect the quality of life and lead to falls with a subsequent increase in the morbidity and mortality. Early identification of gait dysfunction in early stages of PD establishes an effective therapy, prevention of the falls and reducing health care costs. This work aimed to detect gait disorders in patients with PD using the functional gait assessment (FGA) scale and to correlate it with the disease severity in Egyptian PD patients. This is a case–control study in which 40 patients with PD were recruited from the Involuntary Movement Clinic at Alexandria University El-Hadara Hspoital; 20 patients had early stages of PD (Hoehn Yahr stages 1 and 2) and 20 patients had advanced PD (Hoehn Yahr stages 3 and 4). Another 20 subjects were recruited as controls. All recruited subjects underwent gait assessment using FGA scale.
Results
Gait analysis using FGA showed significant differences (P < 0.001) between the recruited PD patients and the control group. Upon comparing the early and advanced PD patients’ groups, certain items in the FGA (gait with pivot turn, step over obstacle, gait with eyes closed and backward gait) together with time consumed for 6-m walk with eyes open and close showed significant statistical differences between early and advanced PD patients. The patients’ duration of illness with PD was reversely correlated with the total FGA score.
Conclusion
The FGA scale was strongly influenced by the duration of PD among the Egyptian patients and can potentially detect early stages of PD.
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The effect of levodopa on bilateral coordination and gait asymmetry in Parkinson's disease using inertial sensor. NPJ PARKINSONS DISEASE 2021; 7:42. [PMID: 33990608 PMCID: PMC8121791 DOI: 10.1038/s41531-021-00186-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 03/17/2021] [Indexed: 11/09/2022]
Abstract
This study aimed to evaluate the effect of levodopa on the phase coordination index (PCI) and gait asymmetry (GA) of patients with Parkinson's disease (PD) and to investigate correlations between the severity of motor symptoms and gait parameters measured using an inertial sensor. Twenty-six patients with mild-to-moderate-stage PD who were taking levodopa participated in this study. The Unified Parkinson's Disease Rating Scale part III (UPDRS III) was used to assess the severity of motor impairment. The Postural Instability and Gait Difficulty (PIGD) subscore was calculated from UPDRS III. Patients were assessed while walking a 20-m corridor in both "OFF" and "ON" levodopa medication states, and gait analysis was performed using inertial sensors. We investigated the changes in gait parameters after taking levodopa and the correlations between UPDRS III, PIGD, and gait parameters. There was a significant improvement in PCI after taking levodopa. No significant effect of levodopa on GA was found. In "OFF" state, PCI and GA were not correlated with UPDRS III and PIGD. However, in "ON" state, PCI was the only gait parameter correlating with UPDRS III, and it was also highly correlated with PIGD compared to other gait parameters. Significant improvement in bilateral-phase coordination was identified in patients with PD after taking levodopa, without significant change in gait symmetricity. Considering the high correlation with UDPRS III and PIGD in "ON" states, PCI may be a useful and quantitative parameter to measure the severity of motor symptoms in PD patients who are on medication.
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Delafontaine A, Hansen C, Marolleau I, Kratzenstein S, Gouelle A. Effect of a Concurrent Cognitive Task, with Stabilizing Visual Information and Withdrawal, on Body Sway Adaptation of Parkinsonian's Patients in an Off-Medication State: A Controlled Study. SENSORS (BASEL, SWITZERLAND) 2020; 20:E5059. [PMID: 32899926 PMCID: PMC7571225 DOI: 10.3390/s20185059] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 09/02/2020] [Accepted: 09/04/2020] [Indexed: 12/23/2022]
Abstract
Background: In persons with Parkinson's disease (pwPD) any additional somatosensory or distractor interference can influence the posture. When deprivation of vision and dual-task are associated, the effect on biomechanical performance is less consistent. The aim of this study was to evaluate the role of the visual deprivation and a cognitive task on the static balance in earlier stage PD subjects. Methods: Fifteen off-medication state pwPD (9 women and 6 men), 67.7 ± 7.3 years old, diagnosed PD since 5.4 ± 3.4 years, only Hoehn and Yahr state 2 and fifteen young control adults (7 women and 8 men) aged 24.9 ± 4.9 years, performed semi-tandem task under four randomized experimental conditions: eyes opened single-task, eyes closed single-task, eyes opened dual-task and eyes closed dual-task. The center of pressure (COP) was measured using a force plate and electromyography signals (EMG) of the ankle/hip muscles were recorded. Traditional parameters, including COP pathway length, ellipse area, mediolateral/anteroposterior root-mean-square and non-linear measurements were computed. The effect of vision privation, cognitive task, and vision X cognitive was investigated by a 2 (eyes opened/eyes closed) × 2 (postural task alone/with cognitive task) repeated-measures ANOVA after application of a Bonferroni pairwise correction for multiple comparisons. Significant interactions were further analyzed using post-hoc tests. Results: In pwPD, both COP pathway length (p < 0.01), ellipse area (p < 0.01) and mediolateral/anteroposterior root-mean-square (p < 0.01) were increased with the eyes closed, while the dual-task had no significant effect when compared to the single-task condition. Comparable results were observed in the control group for who COP pathway was longer in all conditions compared to eyes opened single-task (p < 0.01) and longer in conditions with eyes closed compared to eyes opened dual-task (p < 0.01). Similarly, all differences in EMG activity of pwPD were exclusively observed between eyes opened vs. eyes closed conditions, and especially for the forward leg's soleus (p < 0.01) and backward tibialis anterior (p < 0.01). Conclusions: These results in pwPD without noticeable impairment of static balance encourage the assessment of both visual occlusion and dual-task conditions when the appearance of significant alteration during the dual-task could reveal the subtle worsening onset of the balance control.
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Affiliation(s)
- Arnaud Delafontaine
- CIAMS, University Paris-Sud, Université Paris-Saclay, 91405 Orsay, France;
- CIAMS, Université d’Orléans, 45067 Orléans, France
| | - Clint Hansen
- Department of Neurology, University Hospital Schleswig-Holstein, Christian-Albrechts-Universität zu Kiel, 24098 Kiel, Germany;
| | - Iris Marolleau
- CIAMS, University Paris-Sud, Université Paris-Saclay, 91405 Orsay, France;
- CIAMS, Université d’Orléans, 45067 Orléans, France
| | - Stefan Kratzenstein
- CAU Motion Lab, Kiel University, Olshausenstraße 74, 24098 Kiel, Germany;
- Institute of Sport Science, Kiel University, Olshausenstraße 74, 24098 Kiel, Germany
| | - Arnaud Gouelle
- ProtoKinetics, Havertown, PA 19083, USA;
- Laboratory Performance, Santé, Métrologie, Société (PSMS), UFR STAPS, 51100 Reims, France
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Degani AM, Cardoso VS, Magalhães AT, Assunção ALS, Soares EDC, Danna-Dos-Santos A. Postural Behavior in Medicated Parkinson Disease Patients: A Preliminary Study Searching for Indicators to Track Progress. J Cent Nerv Syst Dis 2020; 12:1179573520922645. [PMID: 32536782 PMCID: PMC7268163 DOI: 10.1177/1179573520922645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 03/16/2020] [Indexed: 11/25/2022] Open
Abstract
Purpose: The establishment of early diagnostic methods for Parkinson disease (PD) is one of the key features to clinically control the rate of PD progression. This study aimed to give a first step toward recognizing the efficacy of multiple postural indices of balance control in differentiating medicated PD patients from health participants. Methods: Nine individuals with PD (Hoehn and Yahr Stage up to 2), 9 staged 2.5 and up, and 9 healthy age-matched Controls performed bipedal stances for 120 seconds with eyes either open or closed on a stable force platform. All participants with PD were under anti-Parkinsonian medication. Non-parametric tests investigated the effects of PD and visual input on postural indices extracted from the center of pressure coordinates. Results: Independent of the stage of the disease, individuals with PD presented faster and shakier body sway compared with Controls. Advanced stages of PD also revealed increased body sway length and variability. In addition, medio-lateral postural instability was more pronounced in all stages of PD when visual inputs were not allowed. Conclusion and Significance: Body sway velocity, jerkiness, length, and its variability revealed to be potential markers for subclinical signs of adjustments in the neuromechanisms of balance control and postural instability even at early stages of disease and under anti-Parkinsonian medication. Results produced here will direct future studies aiming to investigate the efficacy of these same indices on recognizing subclinical development of PD as well as those individuals susceptible to faster rates of progression.
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Affiliation(s)
- Adriana Menezes Degani
- Department of Physical Therapy, Western Michigan University, Kalamazoo, MI, USA.,Unified Clinics, Western Michigan University, Kalamazoo, MI, USA.,Synergy Applied Medical & Research, Missoula, MT, USA
| | - Vinicius Saura Cardoso
- BioSignal Laboratory, School of Physical Therapy, Federal University of Piauí, Parnaíba, Brazil
| | | | | | | | - Alessander Danna-Dos-Santos
- Department of Physical Therapy, Western Michigan University, Kalamazoo, MI, USA.,Synergy Applied Medical & Research, Missoula, MT, USA
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Barbieri FA, Carpenter M, Beretta VS, Orcioli-Silva D, Simieli L, Vitório R, Gobbi LTB. Postural control, falls and Parkinson’s disease: Are fallers more asymmetric than non-fallers? Hum Mov Sci 2019; 63:129-137. [DOI: 10.1016/j.humov.2018.10.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 10/10/2018] [Accepted: 10/17/2018] [Indexed: 10/27/2022]
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Roelofs JMB, van Heugten K, de Kam D, Weerdesteyn V, Geurts ACH. Relationships Between Affected-Leg Motor Impairment, Postural Asymmetry, and Impaired Body Sway Control After Unilateral Supratentorial Stroke. Neurorehabil Neural Repair 2018; 32:953-960. [PMID: 30411675 PMCID: PMC6238182 DOI: 10.1177/1545968318804405] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The relationships between motor impairment of the affected leg, postural control asymmetry, and impaired body sway control after stroke are not well understood. OBJECTIVE To examine the relationship between motor impairment of the affected leg and reduced contribution of this leg to body sway control (ie, dynamic control asymmetry [DCA]) and to determine the relationships between impaired body sway control, DCA, and weight-bearing asymmetry (WBA). METHODS We assessed quiet-standing balance with eyes open in 70 persons with a unilateral supratentorial chronic stroke using 2 force plates. Center-of-pressure (COP) velocity was calculated for both feet together in the anteroposterior (AP) and mediolateral (ML) directions as a measure of body sway control. Bilateral AP COP velocities were used to calculate an index for DCA and weight borne on each side to calculate WBA. Fugl-Meyer assessment of the lower extremity (FMA-LE; range: 0-28) served as a measure of affected-leg motor impairment. RESULTS All participants with FMA-LE <24 showed pronounced DCA, but this was also true for 21% of those with FMA ⩾24. Higher DCA values were related to more WBA ( rs = 0.496; P < .001), and less ML sway control ( rs = 0.268; P = .025). AP sway control was not significantly related to either DCA or WBA. CONCLUSIONS Even clinically well-recovered stroke survivors with (near) maximal FMA-LE scores may show clear postural asymmetry in terms of the relative contribution of the affected leg to body sway control. WBA seems to be an effective compensatory mechanism to optimize the contribution of the less-affected leg to balance, particularly in the AP direction.
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Affiliation(s)
- Jolanda M B Roelofs
- 1 Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kirsten van Heugten
- 1 Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Digna de Kam
- 1 Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Vivian Weerdesteyn
- 1 Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands.,2 Sint Maartenskliniek, Research, Nijmegen, The Netherlands
| | - Alexander C H Geurts
- 1 Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands.,2 Sint Maartenskliniek, Research, Nijmegen, The Netherlands
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Abstract
This study aimed to determine the relationship between postural asymmetry and falls in Parkinson's disease (PD). In total, 28 patients with PD were included. Postural control was analyzed in bipedal, tandem, and unipedal standing. Center of pressure (CoP) parameters were calculated for both limbs, and asymmetry was assessed using the asymmetry index. Logistic regression was used to predict/classify fallers through postural asymmetry. The Spearman correlation was performed to relate asymmetry and falls number. Poisson regression models were created to predict the number of falls in each condition. The results demonstrated that asymmetry can classify 75% of fallers and nonfallers. Asymmetry in anteroposterior-mean velocity of CoP in unipedal standing was related to the number of falls. Poisson regression showed that anteroposterior-mean velocity of CoP predicts falls in PD, indicating that increased asymmetry results in a greater number of falls. Anteroposterior-mean velocity of CoP seems to be a sensitive parameter to detect falls in PD, mainly during a postural challenging task.
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Weilnau JN, Carcella MA, Miner KM, Bhatia TN, Hutchison DF, Pant DB, Nouraei N, Leak RK. Evidence for cross-hemispheric preconditioning in experimental Parkinson's disease. Brain Struct Funct 2018; 223:1255-1273. [PMID: 29103154 PMCID: PMC11061878 DOI: 10.1007/s00429-017-1552-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 10/19/2017] [Indexed: 12/12/2022]
Abstract
Dopamine loss and motor deficits in Parkinson's disease typically commence unilaterally and remain asymmetric for many years, raising the possibility that endogenous defenses slow the cross-hemispheric transmission of pathology. It is well-established that the biological response to subtoxic stress prepares cells to survive subsequent toxic challenges, a phenomenon known as preconditioning, tolerance, or stress adaptation. Here we demonstrate that unilateral striatal infusions of the oxidative toxicant 6-hydroxydopamine (6-OHDA) precondition the contralateral nigrostriatal pathway against the toxicity of a second 6-OHDA infusion in the opposite hemisphere. 6-OHDA-induced loss of dopaminergic terminals in the contralateral striatum was ablated by cross-hemispheric preconditioning, as shown by two independent markers of the dopaminergic phenotype, each measured by two blinded observers. Similarly, loss of dopaminergic somata in the contralateral substantia nigra was also abolished, according to two blinded measurements. Motor asymmetries in floor landings, forelimb contacts with a wall, and spontaneous turning behavior were consistent with these histological observations. Unilateral 6-OHDA infusions increased phosphorylation of the kinase ERK2 and expression of the antioxidant enzyme CuZn superoxide dismutase in both striata, consistent with our previous mechanistic work showing that these two proteins mediate preconditioning in dopaminergic cells. These findings support the existence of cross-hemispheric preconditioning in Parkinson's disease and suggest that dopaminergic neurons mount impressive natural defenses, despite their reputation as being vulnerable to oxidative injury. If these results generalize to humans, Parkinson's pathology may progress slowly and asymmetrically because exposure to a disease-precipitating insult induces bilateral upregulation of endogenous defenses and elicits cross-hemispheric preconditioning.
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Affiliation(s)
- Justin N Weilnau
- Division of Pharmaceutical Sciences, Duquesne University, 407 Mellon Hall, 600 Forbes Ave, Pittsburgh, PA, 15282, USA
| | - Michael A Carcella
- Division of Pharmaceutical Sciences, Duquesne University, 407 Mellon Hall, 600 Forbes Ave, Pittsburgh, PA, 15282, USA
| | - Kristin M Miner
- Division of Pharmaceutical Sciences, Duquesne University, 407 Mellon Hall, 600 Forbes Ave, Pittsburgh, PA, 15282, USA
| | - Tarun N Bhatia
- Division of Pharmaceutical Sciences, Duquesne University, 407 Mellon Hall, 600 Forbes Ave, Pittsburgh, PA, 15282, USA
| | - Daniel F Hutchison
- Division of Pharmaceutical Sciences, Duquesne University, 407 Mellon Hall, 600 Forbes Ave, Pittsburgh, PA, 15282, USA
| | - Deepti B Pant
- Division of Pharmaceutical Sciences, Duquesne University, 407 Mellon Hall, 600 Forbes Ave, Pittsburgh, PA, 15282, USA
| | - Negin Nouraei
- Division of Pharmaceutical Sciences, Duquesne University, 407 Mellon Hall, 600 Forbes Ave, Pittsburgh, PA, 15282, USA
| | - Rehana K Leak
- Division of Pharmaceutical Sciences, Duquesne University, 407 Mellon Hall, 600 Forbes Ave, Pittsburgh, PA, 15282, USA.
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Ribeiro TS, de Sousa AC, de Lucena LC, Santiago LMM, Lindquist ARR. Does dual task walking affect gait symmetry in individuals with Parkinson’s disease? EUROPEAN JOURNAL OF PHYSIOTHERAPY 2018. [DOI: 10.1080/21679169.2018.1444086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Tatiana S. Ribeiro
- Department of Physical Therapy, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Angélica C. de Sousa
- Department of Physical Therapy, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Larissa C. de Lucena
- Department of Physical Therapy, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Lorenna M. M. Santiago
- Department of Physical Therapy, Federal University of Rio Grande do Norte, Natal, Brazil
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An Overview of the Physiology and Pathophysiology of Postural Control. BIOSYSTEMS & BIOROBOTICS 2018. [DOI: 10.1007/978-3-319-72736-3_1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Crouse JJ, Phillips JR, Jahanshahi M, Moustafa AA. Postural instability and falls in Parkinson’s disease. Rev Neurosci 2016; 27:549-55. [DOI: 10.1515/revneuro-2016-0002] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Accepted: 02/14/2016] [Indexed: 01/08/2023]
Abstract
AbstractPostural instability (PI) is one of the most debilitating motor symptoms of Parkinson’s disease (PD), as it is associated with an increased risk of falls and subsequent medical complications (e.g. fractures), fear of falling, decreased mobility, self-restricted physical activity, social isolation, and decreased quality of life. The pathophysiological mechanisms underlying PI in PD remain elusive. This short review provides a critical summary of the literature on PI in PD, covering the clinical features, the neural and cognitive substrates, and the effects of dopaminergic medications and deep brain stimulation. The delayed effect of dopaminergic medication combined with the success of extrastriatal deep brain stimulation suggests that PI involves neurotransmitter systems other than dopamine and brain regions extending beyond the basal ganglia, further challenging the traditional view of PD as a predominantly single-system neurodegenerative disease.
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Affiliation(s)
- Jacob J. Crouse
- 1School of Social Sciences and Psychology, Western Sydney University, Sydney, New South Wales, 2214, Australia
| | - Joseph R. Phillips
- 1School of Social Sciences and Psychology, Western Sydney University, Sydney, New South Wales, 2214, Australia
| | - Marjan Jahanshahi
- 2Cognitive Motor Neuroscience Group and Unit of Functional Neurosurgery Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, The National Hospital for Neurology and Neurosurgery London, WC1N 3BG, UK
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Cattaneo D, Carpinella I, Aprile I, Prosperini L, Montesano A, Jonsdottir J. Comparison of upright balance in stroke, Parkinson and multiple sclerosis. Acta Neurol Scand 2016; 133:346-54. [PMID: 26234280 DOI: 10.1111/ane.12466] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Multiple sclerosis (MS), Parkinson's disease (PD) and stroke (ST) subjects show balance impairments due to damage of the balance control system. The objective of the study was to assess the impact of MS, PD and ST on upright posture in eyes open condition and when visual and/or proprioceptive inputs are altered. MATERIALS AND METHODS A total of 188 subjects with MS (n = 80), PD (n = 58) and ST (n = 50), mean age (SD), 57.9 (14.6) years, and 32 healthy subjects (HS) aged 53.7 (15.7) years were assessed by a stabilometric platform in a cross-sectional study. RESULTS Compared to HS, MS showed large deviations from normal performances with respect to magnitude (P < 0.001) and regularity (P < 0.05) of body sway irrespective of the altered sensory information. Similarly to MS, PD showed large and abnormal levels of body sway (P < 0.001) and postural tremor (P < 0.05), while ST was the least impaired except for an asymmetrical distribution of body weight between legs (P < 0.001). Finally, the MS group compared to PD and ST showed the largest body instability after eye closure (P < 0.05) and when visual and proprioceptive inputs were removed (P < 0.05). PD showed instability mainly after the alteration of proprioceptive inputs (P < 0.05), while ST showed the smallest increase of body instability when sensory inputs were reduced. DISCUSSION Objective assessment revealed pathology-specific balance disorders and showed the differential impact of MS, PD and ST on the ability to use sensory information for balance control.
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Affiliation(s)
- D. Cattaneo
- Don Gnocchi Foundation I.R.C.C.S.; Rome Italy
| | | | - I. Aprile
- Don Gnocchi Foundation I.R.C.C.S.; Rome Italy
| | - L. Prosperini
- Department of Neurology and Psychiatry; La Sapienza University; Rome Italy
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Chagdes JR, Huber JE, Saletta M, Darling-White M, Raman A, Rietdyk S, Zelaznik HN, Haddad JM. The relationship between intermittent limit cycles and postural instability associated with Parkinson's disease. JOURNAL OF SPORT AND HEALTH SCIENCE 2016; 5:14-24. [PMID: 30356531 PMCID: PMC6188581 DOI: 10.1016/j.jshs.2016.01.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 06/06/2015] [Accepted: 11/20/2015] [Indexed: 05/20/2023]
Abstract
BACKGROUND Many disease-specific factors such as muscular weakness, increased muscle stiffness, varying postural strategies, and changes in postural reflexes have been shown to lead to postural instability and fall risk in people with Parkinson's disease (PD). Recently, analytical techniques, inspired by the dynamical systems perspective on movement control and coordination, have been used to examine the mechanisms underlying the dynamics of postural declines and the emergence of postural instabilities in people with PD. METHODS A wavelet-based technique was used to identify limit cycle oscillations (LCOs) in the anterior-posterior (AP) postural sway of people with mild PD (n = 10) compared to age-matched controls (n = 10). Participants stood on a foam and on a rigid surface while completing a dual task (speaking). RESULTS There was no significant difference in the root mean square of center of pressure between groups. Three out of 10 participants with PD demonstrated LCOs on the foam surface, while none in the control group demonstrated LCOs. An inverted pendulum model of bipedal stance was used to demonstrate that LCOs occur due to disease-specific changes associated with PD: time-delay and neuromuscular feedback gain. CONCLUSION Overall, the LCO analysis and mathematical model appear to capture the subtle postural instabilities associated with mild PD. In addition, these findings provide insights into the mechanisms that lead to the emergence of unstable posture in patients with PD.
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Affiliation(s)
- James R. Chagdes
- Department of Mechanical and Manufacturing Engineering, Miami University, Oxford, OH 45056, USA
| | - Jessica E. Huber
- Department of Speech, Language, and Hearing Sciences, Purdue University, West Lafayette, IN 47907, USA
| | - Meredith Saletta
- Department of Communication Sciences and Disorders, University of Iowa, Iowa City, IA 52242, USA
| | - Meghan Darling-White
- Department of Speech, Language, and Hearing Sciences, University of Arizona, Tucson, AZ 85721, USA
| | - Arvind Raman
- School of Mechanical Engineering, Purdue University, West Lafayette, IN 47907, USA
| | - Shirley Rietdyk
- Department of Health and Kinesiology, Purdue University, West Lafayette, IN 47907, USA
| | - Howard N. Zelaznik
- Department of Health and Kinesiology, Purdue University, West Lafayette, IN 47907, USA
| | - Jeffrey M. Haddad
- Department of Health and Kinesiology, Purdue University, West Lafayette, IN 47907, USA
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Abstract
People with Parkinson's disease exhibit debilitating gait impairments, including gait slowness, increased step variability, and poor postural control. A widespread supraspinal locomotor network including the cortex, cerebellum, basal ganglia, and brain stem contributes to the control of human locomotion, and altered activity of these structures underlies gait dysfunction due to Parkinson's disease.
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Affiliation(s)
- D S Peterson
- Veterans Affairs Portland Health Care System (VAPORHCS), Portland, Oregon; and Oregon Health & Science University, Department of Neurology, Portland, Oregon
| | - F B Horak
- Veterans Affairs Portland Health Care System (VAPORHCS), Portland, Oregon; and Oregon Health & Science University, Department of Neurology, Portland, Oregon
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Boonstra TA, van Kordelaar J, Engelhart D, van Vugt JPP, van der Kooij H. Asymmetries in reactive and anticipatory balance control are of similar magnitude in Parkinson's disease patients. Gait Posture 2016; 43:108-13. [PMID: 26475760 DOI: 10.1016/j.gaitpost.2015.08.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 07/21/2015] [Accepted: 08/31/2015] [Indexed: 02/02/2023]
Abstract
Many Parkinson's disease (PD) patients show asymmetries in balance control during quiet stance and in response to perturbations (i.e., reactive balance control) in the sagittal plane. In addition, PD patients show a reduced ability to anticipate to self-induced disturbances, but it is not clear whether these anticipatory responses can be asymmetric too. Furthermore, it is not known how reactive balance control and anticipatory balance control are related in PD patients. Therefore, we investigated whether reactive and anticipatory balance control are asymmetric to the same extent in PD patients. 14 PD patients and 10 controls participated. Reactive balance control (RBC) was investigated by applying external platform and force perturbations and relating the response of the left and right ankle torque to the body sway angle at the excited frequencies. Anticipatory postural adjustments (APAs) were investigated by determining the increase in the left and right ankle torque just before the subjects released a force exerted with the hands against a force sensor. The symmetry ratio between the contribution of the left and right ankle was used to express the asymmetry in reactive and anticipatory balance control; the correlation between the two ratio's was investigated with Spearman's rank correlation coefficients. PD patients were more asymmetric in anticipatory (p=0.026) and reactive balance control (p=0.004) compared to controls and the symmetry ratios were significantly related (ρ=0.74; p=0.003) in PD patients. These findings suggest that asymmetric reactive balance control during bipedal stance may share a common pathophysiology with asymmetries in the anticipation of voluntary perturbations during, for instance, gait initiation.
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Affiliation(s)
- Tjitske A Boonstra
- Laboratory of Biomechanical Engineering, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands; Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands.
| | - Joost van Kordelaar
- Laboratory of Biomechanical Engineering, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands
| | - Denise Engelhart
- Laboratory of Biomechanical Engineering, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands
| | | | - Herman van der Kooij
- Laboratory of Biomechanical Engineering, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands; Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands
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Barbieri FA, Polastri PF, Baptista AM, Lirani-Silva E, Simieli L, Orcioli-Silva D, Beretta VS, Gobbi LTB. Effects of disease severity and medication state on postural control asymmetry during challenging postural tasks in individuals with Parkinson's disease. Hum Mov Sci 2015; 46:96-103. [PMID: 26741255 DOI: 10.1016/j.humov.2015.12.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Revised: 12/01/2015] [Accepted: 12/17/2015] [Indexed: 11/19/2022]
Abstract
The aim of this study was to investigate the effects of disease severity and medication state on postural control asymmetry during challenging tasks in individuals with Parkinson's disease (PD). Nineteen people with PD and 11 neurologically healthy individuals performed three standing task conditions: bipedal standing, tandem and unipedal adapted standing; the individuals with PD performed the tasks in ON and OFF medication state. The participants with PD were distributed into 2 groups according to disease severity: unilateral group (n=8) and bilateral group (n=11). The two PD groups performed the evaluations both under and without the medication. Two force plates were used to analyze the posture. The symmetric index was calculated for various of center of pressure. ANOVA one-way (groups) and two-way (PD groups×medication), with repeated measures for medication, were calculated. For main effects of group, the bilateral group was more asymmetric than CG. For main effects of medication, only unipedal adapted standing presented effects of PD medication. There was PD groups×medication interaction. Under the effects of medication, the unilateral group presented lower asymmetry of RMS in anterior-posterior direction and area than the bilateral group in unipedal adapted standing. In addition, the unilateral group presented lower asymmetry of mean velocity, RMS in anterior-posterior direction and area in unipedal standing and area in tandem adapted standing after a medication dose. Postural control asymmetry during challenging postural tasks was dependent on disease severity and medication state in people with PD. The bilateral group presented higher postural control asymmetry than the control and unilateral groups in challenging postural tasks. Finally, the medication dose was able to reduce postural control asymmetry in the unilateral group during challenging postural tasks.
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Affiliation(s)
- Fabio A Barbieri
- Univ Estadual Paulista - Campus Rio Claro, Posture and Gait Studies Laboratory, Av. 24-A, 1515, Rio Claro, SP CEP: 13506-900, Brazil; Univ Estadual Paulista - Campus Bauru, Laboratory of Human Movement Research, Laboratory of Information, Vision and Action, Av. Eng. Luiz Edmundo Carrijo Coube, 14-01, Bauru, SP CEP: 17033-360, Brazil.
| | - Paula F Polastri
- Univ Estadual Paulista - Campus Bauru, Laboratory of Human Movement Research, Laboratory of Information, Vision and Action, Av. Eng. Luiz Edmundo Carrijo Coube, 14-01, Bauru, SP CEP: 17033-360, Brazil
| | - André M Baptista
- Univ Estadual Paulista - Campus Rio Claro, Posture and Gait Studies Laboratory, Av. 24-A, 1515, Rio Claro, SP CEP: 13506-900, Brazil; Univ Estadual Paulista - Campus Bauru, Laboratory of Human Movement Research, Laboratory of Information, Vision and Action, Av. Eng. Luiz Edmundo Carrijo Coube, 14-01, Bauru, SP CEP: 17033-360, Brazil
| | - Ellen Lirani-Silva
- Univ Estadual Paulista - Campus Rio Claro, Posture and Gait Studies Laboratory, Av. 24-A, 1515, Rio Claro, SP CEP: 13506-900, Brazil
| | - Lucas Simieli
- Univ Estadual Paulista - Campus Rio Claro, Posture and Gait Studies Laboratory, Av. 24-A, 1515, Rio Claro, SP CEP: 13506-900, Brazil
| | - Diego Orcioli-Silva
- Univ Estadual Paulista - Campus Rio Claro, Posture and Gait Studies Laboratory, Av. 24-A, 1515, Rio Claro, SP CEP: 13506-900, Brazil
| | - Victor S Beretta
- Univ Estadual Paulista - Campus Rio Claro, Posture and Gait Studies Laboratory, Av. 24-A, 1515, Rio Claro, SP CEP: 13506-900, Brazil
| | - Lilian T B Gobbi
- Univ Estadual Paulista - Campus Rio Claro, Posture and Gait Studies Laboratory, Av. 24-A, 1515, Rio Claro, SP CEP: 13506-900, Brazil
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Lahr J, Pereira MP, Pelicioni PHS, De Morais LC, Gobbi LTB. PARKINSON'S DISEASE PATIENTS WITH DOMINANT HEMIBODY AFFECTED BY THE DISEASE RELY MORE ON VISION TO MAINTAIN UPRIGHT POSTURAL CONTROL. Percept Mot Skills 2015; 121:923-34. [PMID: 26654986 DOI: 10.2466/15.pms.121c26x0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study assesses the association between disease onset side (dominant or non-dominant) and vision on postural control of Parkinson's disease patients. Patient volunteers composed two groups, according to the onset side affected: Dominant group (n=9; M age=66.1 yr., SD=7.2; 6 women, 3 men) and Non-dominant group (n=9; M age=67.4 yr., SD=6.4; 6 women, 3 men). The groups' postural control was assessed by posturography during quiet upright stance in two conditions, Eyes open and Eyes closed. Two-way analyses of variance (ANOVAs; group×condition) with repeated measures for the second factor assessed the differences associated with affected hemibody and vision on postural control. Analyses indicated that patients with the dominant side affected also presented significantly greater variation in center of pressure than those with the non-dominant side affected, mainly in the Eyes closed condition. The results demonstrate a higher reliance on vision in the dominant side, possibly to compensate somatosensory system impairments. These results also highlight the importance of analyzing the hemibody affected by the disease when postural control is assessed in this population.
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Resistance versus Balance Training to Improve Postural Control in Parkinson's Disease: A Randomized Rater Blinded Controlled Study. PLoS One 2015; 10:e0140584. [PMID: 26501562 PMCID: PMC4621054 DOI: 10.1371/journal.pone.0140584] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 09/25/2015] [Indexed: 12/31/2022] Open
Abstract
Background Reduced muscle strength is an independent risk factor for falls and related to postural instability in individuals with Parkinson’s disease. The ability of resistance training to improve postural control still remains unclear. Objective To compare resistance training with balance training to improve postural control in people with Parkinson’s disease. Methods 40 patients with idiopathic Parkinson’s disease (Hoehn&Yahr: 2.5–3.0) were randomly assigned into resistance or balance training (2x/week for 7 weeks). Assessments were performed at baseline, 8- and 12-weeks follow-up: primary outcome: Fullerton Advanced Balance (FAB) scale; secondary outcomes: center of mass analysis during surface perturbations, Timed-up-and-go-test, Unified Parkinson’s Disease Rating Scale, Clinical Global Impression, gait analysis, maximal isometric leg strength, PDQ-39, Beck Depression Inventory. Clinical tests were videotaped and analysed by a second rater, blind to group allocation and assessment time. Results 32 participants (resistance training: n = 17, balance training: n = 15; 8 drop-outs) were analyzed at 8-weeks follow-up. No significant difference was found in the FAB scale when comparing the effects of the two training types (p = 0.14; effect size (Cohen’s d) = -0.59). Participants from the resistance training group, but not from the balance training group significantly improved on the FAB scale (resistance training: +2.4 points, Cohen’s d = -0.46; balance training: +0.3 points, Cohen’s d = -0.08). Within the resistance training group, improvements of the FAB scale were significantly correlated with improvements of rate of force development and stride time variability. No significant differences were found in the secondary outcome measures when comparing the training effects of both training types. Conclusions The difference between resistance and balance training to improve postural control in people with Parkinson’s disease was small and not significant with this sample size. There was weak evidence that freely coordinated resistance training might be more effective than balance training. Our results indicate a relationship between the enhancement of rate of force development and the improvement of postural control. Trial Registration ClinicalTrials.gov ID: NCT02253563
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23
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Crétual A. Which biomechanical models are currently used in standing posture analysis? Neurophysiol Clin 2015; 45:285-95. [PMID: 26388359 DOI: 10.1016/j.neucli.2015.07.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 07/23/2015] [Indexed: 12/22/2022] Open
Abstract
In 1995, David Winter concluded that postural analysis of upright stance was often restricted to studying the trajectory of the center of pressure (CoP). However, postural control means regulation of the center of mass (CoM) with respect to CoP. As CoM is only accessible by using a biomechanical model of the human body, the present article proposes to determine which models are actually used in postural analysis, twenty years after Winter's observation. To do so, a selection of 252 representative articles dealing with upright posture and published during the four last years has been checked. It appears that the CoP model largely remains the most common one (accounting for nearly two thirds of the selection). Other models, CoP/CoM and segmental models (with one, two or more segments) are much less used. The choice of the model does not appear to be guided by the population studied. Conversely, while some confusion remains between postural control and the associated concepts of stability or strategy, this choice is better justified for real methodological concerns when dealing with such high-level parameters. Finally, the computation of the CoM continues to be a limitation in achieving a more complete postural analysis. This unfortunately implies that the model is chosen for technological reasons in many cases (choice being a euphemism here). Some effort still has to be made so that bioengineering developments allow us to go beyond this limit.
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Affiliation(s)
- A Crétual
- M2S lab (Mouvement Sport Santé), University Rennes 2 - ENS Rennes - UEB, avenue Robert-Schuman, campus de Ker Lann, 35170 Bruz, France; MimeTIC team, INRIA Rennes, campus universitaire de Beaulieu, 35042 Rennes, France.
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24
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Beretta VS, Gobbi LTB, Lirani-Silva E, Simieli L, Orcioli-Silva D, Barbieri FA. Challenging Postural Tasks Increase Asymmetry in Patients with Parkinson's Disease. PLoS One 2015; 10:e0137722. [PMID: 26367032 PMCID: PMC4569579 DOI: 10.1371/journal.pone.0137722] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 08/20/2015] [Indexed: 11/19/2022] Open
Abstract
The unilateral predominance of Parkinson’s disease (PD) symptoms suggests that balance control could be asymmetrical during static tasks. Although studies have shown that balance control asymmetries exist in patients with PD, these analyses were performed using only simple bipedal standing tasks. Challenging postural tasks, such as unipedal or tandem standing, could exacerbate balance control asymmetries. To address this, we studied the impact of challenging standing tasks on postural control asymmetry in patients with PD. Twenty patients with PD and twenty neurologically healthy individuals (control group) participated in this study. Participants performed three 30s trials for each postural task: bipedal, tandem adapted and unipedal standing. The center of pressure parameter was calculated for both limbs in each of these conditions, and the asymmetry between limbs was assessed using the symmetric index. A significant effect of condition was observed, with unipedal standing and tandem standing showing greater asymmetry than bipedal standing for the mediolateral root mean square (RMS) and area of sway parameters, respectively. In addition, a group*condition interaction indicated that, only for patients with PD, the unipedal condition showed greater asymmetry in the mediolateral RMS and area of sway than the bipedal condition and the tandem condition showed greater asymmetry in the area of sway than the bipedal condition. Patients with PD exhibited greater asymmetry while performing tasks requiring postural control when compared to neurologically healthy individuals, especially for challenging tasks such as tandem and unipedal standing.
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Affiliation(s)
- Victor Spiandor Beretta
- Univ Estadual Paulista, UNESP, Posture and Gait Studies Laboratory, Department of Physical Education, Bioscience Institute, Rio Claro, São Paulo, Brazil
| | - Lilian Teresa Bucken Gobbi
- Univ Estadual Paulista, UNESP, Posture and Gait Studies Laboratory, Department of Physical Education, Bioscience Institute, Rio Claro, São Paulo, Brazil
| | - Ellen Lirani-Silva
- Univ Estadual Paulista, UNESP, Posture and Gait Studies Laboratory, Department of Physical Education, Bioscience Institute, Rio Claro, São Paulo, Brazil
| | - Lucas Simieli
- Univ Estadual Paulista, UNESP, Posture and Gait Studies Laboratory, Department of Physical Education, Bioscience Institute, Rio Claro, São Paulo, Brazil
| | - Diego Orcioli-Silva
- Univ Estadual Paulista, UNESP, Posture and Gait Studies Laboratory, Department of Physical Education, Bioscience Institute, Rio Claro, São Paulo, Brazil
| | - Fabio Augusto Barbieri
- Univ Estadual Paulista, UNESP, Posture and Gait Studies Laboratory, Department of Physical Education, Bioscience Institute, Rio Claro, São Paulo, Brazil
- Univ Estadual Paulista, UNESP, Laboratory of Information, Vision and Action, Department of Physical Education, Faculty of Science, Bauru, São Paulo, Brazil
- * E-mail:
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25
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Grajić M, Stanković I, Radovanović S, Kostić V. Gait in drug naïve patients with de novo Parkinson's disease--altered but symmetric. Neurol Res 2015; 37:712-6. [PMID: 25916791 DOI: 10.1179/1743132815y.0000000043] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Motor symptoms in Parkinson's disease (PD) are typically asymmetrical. Early stage of PD is characterised with a predominantly unilateral appearance of tremor, rigidity and bradykinesia, with or without axial involvement. Also, studies have demonstrated gait asymmetry in de novo drug naïve PD patients. Aim of this study was to investigate gait pattern, gait symmetry and gait variability in early phases of PD. METHODS The gait was measured in 40 de novo, drug naïve PD patients and 43 healthy control subjects (HC) while performing a simple walking task. Calculated parameters were cycle time (CT), stride length (SL) and swing time (ST), and their coefficients of variation (CV). RESULTS Considering gait parameters, PD patients and HC differed in terms of all parameters, except for the CV of CT. Analysis of gait symmetry, comparison between the gait patterns of the left and the right leg in PD patients revealed no difference for any of the assessed parameters. The majority of the gait parameters did not differ between left and right legs of HC. CONCLUSIONS It can be concluded that even gait was already altered in de novo drug naive PD patients, gait symmetry remained preserved. The SL was the most prominent parameter of altered gait in initial stages of PD patients, while the ST heralded postural asymmetry.
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Panyakaew P, Anan C, Bhidayasiri R. Visual deprivation elicits subclinical postural inflexibilities in early Parkinson's disease. J Neurol Sci 2015; 349:214-9. [PMID: 25656100 DOI: 10.1016/j.jns.2015.01.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 01/16/2015] [Accepted: 01/19/2015] [Indexed: 10/24/2022]
Abstract
BACKGROUND Postural instability is often experienced in the late stages of PD and is a marker of disease progression. Little information is available on the role of visual inputs as an adaptive strategy to compensate for postural instability in PD. The purpose of this study was to determine visual dependency for postural control in early PD. METHODS Thirty early PD subjects without postural complaints and 30 matched controls were evaluated for subtle postural instability using static posturography under eyes opened and eyes closed conditions. RESULTS No significant differences between groups were observed under eyes opened condition. In eyes closed condition, there was significantly greater mean sway in the mediolateral direction (p=0.01), mean sway velocity (p=0.03), lateral sway velocity (p=0.04), and sway area (p=0.04) in PD than in the control subjects. 95% confidence ellipse of mean sway was largest in PD patients with eyes closed. A strong and significant correlation was observed between disease duration and mean mediolateral sway, sway area, mean sway and lateral sway velocity, and a moderate correlation was shown between Hoehn & Yahr stage and mean mediolateral sway, and sway area. CONCLUSION Our findings suggest that visual dependency exists in early PD and visual deprivation task can help identify subclinical postural instability.
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Affiliation(s)
- Pattamon Panyakaew
- Chulalongkorn Center of Excellence on Parkinson Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
| | - Chanawat Anan
- Chulalongkorn Center of Excellence on Parkinson Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
| | - Roongroj Bhidayasiri
- Chulalongkorn Center of Excellence on Parkinson Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand; Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles 90095, USA.
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27
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Boonstra TA, Schouten AC, van Vugt JPP, Bloem BR, van der Kooij H. Parkinson's disease patients compensate for balance control asymmetry. J Neurophysiol 2014; 112:3227-39. [DOI: 10.1152/jn.00813.2013] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
In Parkinson's disease (PD) subtle balance abnormalities can already be detected in early-stage patients. One feature of impaired balance control in PD is asymmetry: one leg produces more corrective joint torque than the other. We hypothesize that in mild to moderately affected PD patients, the least impaired leg compensates for the more impaired leg. Twenty PD patients and eleven healthy matched control subjects participated. Clinical asymmetry was determined by the difference between the left and right body side scores on the Unified Parkinson's Disease Rating Scale. Balance was perturbed with two independent continuous multisine perturbations in the forward-backward direction. Subsequently, we applied closed-loop system identification, which determined the spectral estimate of the stabilizing mechanisms, for each leg. Balance control behavior was similar in PD patients and control subjects at the ankle, but at the hip stiffness was increased. Control subjects exhibited symmetric balance control, but in PD patients the balance contribution of the leg of the clinically least affected body side was higher whereas the leg of the clinically most affected body side contributed less. The ratio between the legs helped to preserve a normal motor output at the ankle. Our results suggest that PD patients compensate for balance control asymmetries by increasing the relative contribution of the leg of their least affected body side. This compensation appears to be successful at the ankle but is accompanied by an increased stiffness at the hip. We discuss the possible implications of these findings for postural stability and fall risk in PD patients.
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Affiliation(s)
- T. A. Boonstra
- Department of Biomechanical Engineering, University of Twente, MIRA Institute for Biomechanical Technology and Technical Medicine, Enschede, The Netherlands
| | - A. C. Schouten
- Department of Biomechanical Engineering, University of Twente, MIRA Institute for Biomechanical Technology and Technical Medicine, Enschede, The Netherlands
- Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands
| | - J. P. P. van Vugt
- Department of Neurology, Medical Spectrum Twente, Enschede, The Netherlands; and
| | - B. R. Bloem
- Radboud University Nijmegen Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Nijmegen, The Netherlands
| | - H. van der Kooij
- Department of Biomechanical Engineering, University of Twente, MIRA Institute for Biomechanical Technology and Technical Medicine, Enschede, The Netherlands
- Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands
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Boonstra TA, van Vugt JPP, van der Kooij H, Bloem BR. Balance asymmetry in Parkinson's disease and its contribution to freezing of gait. PLoS One 2014; 9:e102493. [PMID: 25032994 PMCID: PMC4102504 DOI: 10.1371/journal.pone.0102493] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 06/20/2014] [Indexed: 11/18/2022] Open
Abstract
Balance control (the ability to maintain an upright posture) is asymmetrically controlled in a proportion of patients with Parkinson's disease. Gait asymmetries have been linked to the pathophysiology of freezing of gait. We speculate that asymmetries in balance could contribute to freezing by a) hampering the unloading of the stepping leg and/or b) leading to a preferred stance leg during gait, which then results in asymmetric gait. To investigate this, we examined the relationship between balance control and weight-bearing asymmetries and freezing. We included 20 human patients with Parkinson (tested OFF medication; nine freezers) and nine healthy controls. Balance was perturbed in the sagittal plane, using continuous multi-sine perturbations, applied by a motion platform and by a force at the sacrum. Applying closed-loop system identification techniques, relating the body sway angle to the joint torques of each leg separately, determined the relative contribution of each ankle and hip joint to the total amount of joint torque. We also calculated weight-bearing asymmetries. We determined the 99-percent confidence interval of weight-bearing and balance-control asymmetry using the responses of the healthy controls. Freezers did not have larger asymmetries in weight bearing (p = 0.85) nor more asymmetrical balance control compared to non-freezers (p = 0.25). The healthy linear one-to-one relationship between weight bearing and balance control was significantly different for freezers and non-freezers (p = 0.01). Specifically, non-freezers had a significant relationship between weight bearing and balance control (p = 0.02), whereas this relation was not significant for freezers (p = 0.15). Balance control is asymmetrical in most patients (about 75 percent) with Parkinson's disease, but this asymmetry is not related to freezing. The relationship between weight bearing and balance control seems to be less pronounced in freezers, compared to healthy controls and non-freezers. However, this relationship should be investigated further in larger groups of patients.
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Affiliation(s)
- Tjitske A. Boonstra
- Department of Biomechanical Engineering, University of Twente, MIRA institute for biomechanical technology and technical medicine, Enschede, The Netherlands
| | | | - Herman van der Kooij
- Department of Biomechanical Engineering, University of Twente, MIRA institute for biomechanical technology and technical medicine, Enschede, The Netherlands
- Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands
| | - Bastiaan R. Bloem
- Radboud University Nijmegen Medical Centre, Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
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Engelhart D, Pasma JH, Schouten AC, Meskers CGM, Maier AB, Mergner T, van der Kooij H. Impaired standing balance in elderly: a new engineering method helps to unravel causes and effects. J Am Med Dir Assoc 2013; 15:227.e1-227.e6. [PMID: 24220138 DOI: 10.1016/j.jamda.2013.09.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Revised: 09/09/2013] [Accepted: 09/11/2013] [Indexed: 11/18/2022]
Abstract
Deteriorated balance control is the most frequent cause of falls and injuries in the elderly. Balance control comprises a complex interplay of several underlying systems (ie, the sensory systems, the motor system, and the nervous system). Available clinical balance tests determine the patient's ability to maintain standing balance under defined test conditions and aim to describe the current state of this ability. However, these tests do not reveal which of the underlying systems is deteriorated and to what extent, so that the relation between cause and effect often remains unclear. Especially detection of early-stage balance control deterioration is difficult, because the balance control system is redundant and elderly may use compensation strategies. This article describes a new method that is able to identify causal relationships in deteriorated balance control, called CLSIT (Closed Loop System Identification Technique). Identification of impaired balance with CLSIT is a base for development of tailored interventions and compensation strategies to reduce the often serious consequences of deteriorated balance control in the elderly.
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Affiliation(s)
- Denise Engelhart
- Laboratory of Biomechanical Engineering, Institute for Biomedical Technology and Technical Medicine (MIRA), University of Twente, Enschede, The Netherlands.
| | - Jantsje H Pasma
- Department of Rehabilitation Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - Alfred C Schouten
- Laboratory of Biomechanical Engineering, Institute for Biomedical Technology and Technical Medicine (MIRA), University of Twente, Enschede, The Netherlands; Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands
| | - Carel G M Meskers
- Department of Rehabilitation Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - Andrea B Maier
- Section of Geriatrics and Gerontology, Department of Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | | | - Herman van der Kooij
- Laboratory of Biomechanical Engineering, Institute for Biomedical Technology and Technical Medicine (MIRA), University of Twente, Enschede, The Netherlands; Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands
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Panyakaew P, Bhidayasiri R. The spectrum of preclinical gait disorders in early Parkinson’s disease: subclinical gait abnormalities and compensatory mechanisms revealed with dual tasking. J Neural Transm (Vienna) 2013; 120:1665-72. [DOI: 10.1007/s00702-013-1051-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2013] [Accepted: 06/10/2013] [Indexed: 11/30/2022]
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Boonstra TA, Schouten AC, van der Kooij H. Identification of the contribution of the ankle and hip joints to multi-segmental balance control. J Neuroeng Rehabil 2013; 10:23. [PMID: 23433148 PMCID: PMC3662596 DOI: 10.1186/1743-0003-10-23] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Accepted: 01/24/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Human stance involves multiple segments, including the legs and trunk, and requires coordinated actions of both. A novel method was developed that reliably estimates the contribution of the left and right leg (i.e., the ankle and hip joints) to the balance control of individual subjects. METHODS The method was evaluated using simulations of a double-inverted pendulum model and the applicability was demonstrated with an experiment with seven healthy and one Parkinsonian participant. Model simulations indicated that two perturbations are required to reliably estimate the dynamics of a double-inverted pendulum balance control system. In the experiment, two multisine perturbation signals were applied simultaneously. The balance control system dynamic behaviour of the participants was estimated by Frequency Response Functions (FRFs), which relate ankle and hip joint angles to joint torques, using a multivariate closed-loop system identification technique. RESULTS In the model simulations, the FRFs were reliably estimated, also in the presence of realistic levels of noise. In the experiment, the participants responded consistently to the perturbations, indicated by low noise-to-signal ratios of the ankle angle (0.24), hip angle (0.28), ankle torque (0.07), and hip torque (0.33). The developed method could detect that the Parkinson patient controlled his balance asymmetrically, that is, the right ankle and hip joints produced more corrective torque. CONCLUSION The method allows for a reliable estimate of the multisegmental feedback mechanism that stabilizes stance, of individual participants and of separate legs.
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Affiliation(s)
- Tjitske Anke Boonstra
- Laboratory for Biomechanical Engineering, MIRA institute for biomechanical technology and technical medicine, University of Twente, Faculty of Engineering Technology, PO Box 217, Enschede, AE 7500, The Netherlands.
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Nardone A, Pasetti C, Schieppati M. Spinal and supraspinal stretch responses of postural muscles in early Parkinsonian patients. Exp Neurol 2012; 237:407-17. [DOI: 10.1016/j.expneurol.2012.07.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Revised: 06/18/2012] [Accepted: 07/07/2012] [Indexed: 11/16/2022]
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Pasma JH, Boonstra TA, Campfens SF, Schouten AC, Van der Kooij H. Sensory reweighting of proprioceptive information of the left and right leg during human balance control. J Neurophysiol 2012; 108:1138-48. [PMID: 22623486 DOI: 10.1152/jn.01008.2011] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
To keep balance, information from different sensory systems is integrated to generate corrective torques. Current literature suggests that this information is combined according to the sensory reweighting hypothesis, i.e., more reliable information is weighted more strongly than less reliable information. In this approach, no distinction has been made between the contributions of both legs. In this study, we investigated how proprioceptive information from both legs is combined to maintain upright stance. Healthy subjects maintained balance with eyes closed while proprioceptive information of each leg was perturbed independently by continuous rotations of the support surfaces (SS) and the human body by platform translation. Two conditions were tested: perturbation amplitude of one SS was increased over trials while the other SS 1) did not move or 2) was perturbed with constant amplitude. With the use of system identification techniques, the response of the ankle torques to the perturbation amplitudes (i.e., the torque sensitivity functions) was determined and how much each leg contributed to stabilize stance (i.e., stabilizing mechanisms) was estimated. Increased amplitude of one SS resulted in a decreased torque sensitivity. The torque sensitivity to the constant perturbed SS showed no significant differences. The properties of the stabilizing mechanisms remained constant during perturbations of each SS. This study demonstrates that proprioceptive information from each leg is weighted independently and that the weight decreases with perturbation amplitude. Weighting of proprioceptive information of one leg has no influence on the weight of the proprioceptive information of the other leg. According to the sensory reweighting hypothesis, vestibular information must be up-weighted, because closing the eyes eliminates visual information.
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Affiliation(s)
- J H Pasma
- Laboratory of Biomechanical Engineering, Institute for Biomedical Technology and Technical Medicine (MIRA), University of Twente, Enschede, The Netherlands.
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Schouten AC, Boonstra TA, Nieuwenhuis F, Campfens SF, van der Kooij H. A Bilateral Ankle Manipulator to Investigate Human Balance Control. IEEE Trans Neural Syst Rehabil Eng 2011; 19:660-9. [DOI: 10.1109/tnsre.2011.2163644] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Roland KP, Jakobi JM, Powell C, Jones GR. Factors related to functional independence in females with Parkinson's disease: A systematic review. Maturitas 2011; 69:304-11. [DOI: 10.1016/j.maturitas.2011.05.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2011] [Accepted: 05/22/2011] [Indexed: 11/28/2022]
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