Mobile Brain Imaging to Examine Task-Related Cortical Correlates of Reactive Balance: A Systematic Review

Linking brain activation to standing balance performance: A systematic review and meta analysis of functional near-infrared spectroscopy literature

BACKGROUND

Functional Near-Infrared Spectroscopy (fNIRS) holds promise for clinical applications in the field of balance impairment amelioration; however, the relationship between fNIRS metrics and balance performance remains uncertain. We aimed to quantify the correlations between fNIRS-derived brain activation and standing balance performance, and determine variables that influence these associations.

METHODS

We systematically reviewed English-language studies, published across PuBMed, PsycINFO, Embase, CINAHL, Ovid Medline, and Web of Science from inception up until July 1, 2024, that assessed standing balance tasks in adults > 18 years old with or without medical diagnosis measured with fNIRS. Pooled correlation coefficients were synthesized using a random effects restricted maximum likelihood model.

RESULTS

Overall, 17 studies were included with 420 participants. Key factors influencing the identified relationships were brain region and participant diagnosis. We identified moderate correlations between balance performance and cortical activation recorded by fNIRS in the supplementary motor area (SMA) (r = 0.52, 95 % CI = 0.39 0.64), and the prefrontal cortex (PFC) (r = 0.47, 95 % CI=0.32 - 0.60). In the PFC, increased oxygenated haemoglobin (HbO) was negatively associated with balance measures. The reverse relationship was reported in the PFC for individuals with physical and cognitive impairment. In the SMA, HbO was positively associated with balance. Few studies found associations between deoxygenated haemoglobin (HbR) and total hemoglobin (HbT) with balance performance.

SIGNIFICANCE

Current evidence supports a relationship between fNIRS measures, specifically HbO, with standing balance performance. This relationship depends on the brain region measured, age, and the diagnosis of the participants. To better understand this relationship, there is a need to report standardized balance performance metrics alongside other metrics of interest to better synthesize data across publications. Improved understanding the neural basis of standing balance with fNIRS will lead to more informed interventions for balance rehabilitation.

Excellent test-retest reliability of perturbation-evoked cortical responses supports feasibility of the balance N1 as a clinical biomarker

There is a growing interest in measuring cortical activity during balance control for understanding mechanisms of impaired balance with aging and neurological dysfunction. The most well-characterized electrophysiological signal elicited by a balance disturbance is the perturbation-evoked N1 potential. We previously found associations between the N1 and balance ability, suggesting it may be a potential biomarker of balance health. However, a potential biomarker will be limited by its reliability and clinical feasibility, which has yet to be established. Here, we characterized the reliability of the balance N1 within and between sessions over a 1-wk interval in 10 younger and 14 older adults, and over a 1-year interval in a subset of older adults (n = 12). We extracted N1 amplitude and latency from the Cz electrode using an advanced, computationally intensive approach (64 electrodes, many trials). Test-retest reliability was assessed using the intraclass correlation coefficient (ICC). Internal consistency was quantified by split-half reliability using the Spearman correlation coefficient. N1s varied across individuals, yet within individuals, showed excellent test-retest reliability (ICC > 0.9) and internal reliability (r > 0.9). N1 amplitude reliability generally plateaued within six trials, whereas more trials were needed to reliably measure latency. Similar results were obtained using a minimal approach (three electrodes, simple preprocessing) and at the component level (largest contributing N1 source). The N1's stability, reliability, and feasibility make it well suited for potential use as a clinical biomarker. Characterizing N1 reliability in different populations and contexts will be necessary to enhance our understanding, optimize experimental design, and determine its predictive validity (e.g., falls risk).NEW & NOTEWORTHY Prior studies identified associations between the perturbation-evoked N1 potential and behaviors that predict falls, suggesting its potential as a biomarker of balance. We show excellent test-retest reliability of the N1 over a year in older adults, and that a reliable measurement can be obtained within six trials using simplified methods, demonstrating clinical feasibility. This study also guides the design of more powerful N1 experiments, necessary to identify underlying mechanisms and assess clinical utility.

Delayed Cortical Responses During Reactive Balance After Stroke Associated With Slower Kinetics and Clinical Balance Dysfunction

BACKGROUND

Slowed balance and mobility after stroke have been well-characterized. Yet the effects of unilateral cortical lesions on whole-body neuromechanical control is poorly understood, despite increased reliance on cortical resources for balance and mobility with aging. Objective. We tested whether individuals post stroke show impaired cortical responses evoked during reactive balance, and the effect of asymmetrical interlimb contributions to balance recovery and the evoked cortical response.

METHODS

Using electroencephalography, we assessed cortical N1 responses evoked over fronto-midline regions (Cz) during backward support-surface perturbations loading both legs and posterior-lateral directions that preferentially load the paretic or nonparetic leg in individuals' post-stroke and age-matched controls. We tested relationships between cortical responses and clinical balance/mobility function, as well as to center of pressure (CoP) rate of rise (RoR) during balance recovery.

RESULTS

Cortical N1 responses were smaller and delayed after stroke (P < .047), regardless of perturbation condition. In contrast to controls, slower cortical response latencies associated with lower clinical function in stroke (Mini Balance Evaluation Systems Test: r = -.61, P = .007; Timed-Up-and-Go: r = .53, P = .024; walking speed: r = -.46, P = .055). Paretic-loaded balance recovery revealed slower CoP RoR (P = .012) that was associated with delayed cortical response latencies (r = -.70, P = .003); these relationships were not present during bilateral and nonparetic-loaded conditions, nor in the older adults control group.

CONCLUSIONS

Individuals after stroke may be limited in their balance ability by the slowed speed of their cortical responses to destabilization. In particular, paretic leg loading may reveal cortical response impairments that reflect reduced paretic motor capacity.

Neuromuscular Mechanisms of Motor Adaptation to Repeated Treadmill-Slip Perturbations During Stance in Healthy Young Adults

Treadmill-based repeated perturbation training (PBT) induces motor adaptation in reactive balance responses, thus lowering the risk of slip-induced falls. However, little evidence exists regarding intervention-induced changes in neuromuscular control underlying motor adaptation. Examining neuromuscular changes could be an important step in identifying key elements of adaptation and evaluating treadmill training protocols for fall prevention. Moreover, identifying the muscle synergies contributing to motor adaptation in young adults could lay the groundwork for comparison with high fall-risk populations. Thus, we aimed to investigate neuromuscular changes in reactive balance responses during stance slip-PBT. Lower limb electromyography (EMG) signals (4/leg) were recorded during ten repeated forward stance (slip-like) perturbations in twenty-six young adults. Muscle synergies were compared between early-training (slips 1-2) and late-training (slips 9-10) stages. Results showed that 5 different modes of synergies (named on dominant muscles: WTA, W , W , W , and W were recruited in both stages. 3 out of 5 synergies (WTA, W , and W showed a high similarity (r >0.97) in structure and activation between stages, whereas W and W showed a lower similarity (r <0.83) between the two stages, and the area of activation in WTA, the peak value of activation in W and the activation onset in W showed a reduction from early- to late-training stage (p <0.05). These results suggest that a block of stance slip-PBT resulted in modest changes in muscle synergies in young adults, which might explain the smaller changes seen in biomechanical variables. Future studies should examine neuromuscular changes in people at high risk of falls.

Early screening of post-stroke fall risk: A simultaneous multimodal fNIRs-EMG study

BACKGROUND

Stroke is the third-leading cause of death and disability, and poststroke falls (PSF) are common at all stages after stroke and could even lead to injuries or death. Brain information from functional near-infrared spectroscopy (fNIRs) may precede conventional imaging and clinical symptoms but has not been systematically considered in PSF risk prediction. This study investigated the difference in brain activation between stroke patients and healthy subjects, and this study was aimed to explore fNIRs biomarkers for early screening of PSF risk by comparing the brain activation in patients at and not at PSF risk.

METHODS

In this study, we explored the differences in brain activation and connectivity between stroke and healthy subjects by synchronizing the detection of fNIRs and EMG tests during simple (usual sit-to-stand) and difficult tasks (sit-to-stand based on EMG feedback). Thereby further screened for neuroimaging biomarkers for early prediction of PSF risk by comparing brain activation variability in poststroke patients at and not at fall risk during simple and difficult tasks. The area under the ROC curve (AUROC), sensitivity, and specificity were used to compare the diagnostic effect.

RESULTS

A total of 40 patients (22 not at and 18 at PSF risk) and 38 healthy subjects were enrolled. As the difficulty of standing task increased, stroke patients compared with healthy subjects further increased the activation of the unaffected side of supplementary motor area (H-SMA) and dorsolateral prefrontal cortex-Brodmann area 46 (H-DLFC-BA46) but were unable to increase functional connectivity (Group*Task: p < 0.05). More importantly, the novel finding showed that hyperactivation of the H-SMA during a simple standing task was a valid fNIRs predictor of PSF risk [AUROC 0.74, p = 0.010, sensitivity 77.8%, specificity 63.6%].

CONCLUSIONS

This study provided novel evidence that fNIR-derived biomarkers could early predict PSF risk that can facilitate the widespread use of real-time assessment tools in early screening and rehabilitation. Meanwhile, this study demonstrated that the higher brain activation and inability to increase the brain functional connectivity in stroke patients during difficult task indicated the inefficient use of brain resources.

Mobile neuroimaging: What we have learned about the neural control of human walking, with an emphasis on EEG-based research

Our understanding of the neural control of human walking has changed significantly over the last twenty years and mobile brain imaging methods have contributed substantially to current knowledge. High-density electroencephalography (EEG) has the advantages of being lightweight and mobile while providing temporal resolution of brain changes within a gait cycle. Advances in EEG hardware and processing methods have led to a proliferation of research on the neural control of locomotion in neurologically intact adults. We provide a narrative review of the advantages and disadvantages of different mobile brain imaging methods, then summarize findings from mobile EEG studies quantifying electrocortical activity during human walking. Contrary to historical views on the neural control of locomotion, recent studies highlight the widespread involvement of many areas, such as the anterior cingulate, posterior parietal, prefrontal, premotor, sensorimotor, supplementary motor, and occipital cortices, that show active fluctuations in electrical power during walking. The electrocortical activity changes with speed, stability, perturbations, and gait adaptation. We end with a discussion on the next steps in mobile EEG research.

Distinct Cortical Correlates of Perception and Motor Function in Balance Control

Fluctuations in brain activity alter how we perceive our body and generate movements but have not been investigated in functional whole-body behaviors. During reactive balance, we recently showed that evoked brain activity is associated with the balance ability in young individuals. Furthermore, in PD, impaired whole-body motion perception in reactive balance is associated with impaired balance. Here, we investigated the brain activity during the whole-body motion perception in reactive balance in young adults (9 female, 10 male). We hypothesized that both ongoing and evoked cortical activity influences the efficiency of information processing for successful perception and movement during whole-body behaviors. We characterized two cortical signals using electroencephalography localized to the SMA: (1) the "N1," a perturbation-evoked potential that decreases in amplitude with expectancy and is larger in individuals with lower balance function, and (2) preperturbation β power, a transient rhythm that favors maintenance of the current sensorimotor state and is inversely associated with tactile perception. In a two-alternative forced choice task, participants judged whether pairs of backward support surface perturbations during standing were in the "same" or "different" direction. As expected, lower whole-body perception was associated with lower balance ability. Within a perturbation pair, N1 attenuation was larger on correctly perceived trials and associated with better balance, but not perception. In contrast, preperturbation β power was higher on incorrectly perceived trials and associated with poorer perception, but not balance. Together, ongoing and evoked cortical activity have unique roles in information processing that give rise to distinct associations with perceptual and balance ability.

Functional electrical stimulation to enhance reactive balance among people with hemiparetic stroke

BACKGROUND

Individuals with stroke demonstrate a twofold higher fall incidence compared to healthy counterparts, potentially associated with deficits in reactive balance control, which is crucial for regaining balance from unpredictable perturbations to the body. Moreover, people with higher stroke-related motor impairment exhibit greater falls and cannot recover balance during higher perturbation intensities. Thus, they might need supplemental agents for fall prevention or even to be included in a perturbation-based protocol. Functional electrical stimulation is a widely used clinical modality for improving gait performance; however, it remains unknown whether it can enhance or interfere with reactive balance control.

METHODS

We recruited twelve ambulatory participants with hemiparetic stroke (61.48 ± 6.77 years) and moderate-to-high motor impairment (Chedoke-McMaster Stroke Leg Assessment ≤ 4/7). Each participant experienced 4 unpredicted paretic gait-slips, with and without functional electrical stimulation (provided 50-500 ms after perturbation) in random order. The paretic quadriceps muscle group was chosen to receive electrical stimulation, considering the role of support limb knee extensors for preventing limb-collapse. Outcomes including primary (laboratory falls), secondary (reactive stability, vertical limb support) and tertiary (compensatory step length, step initiation, execution time) measures were compared between the two conditions.

RESULTS

Participants demonstrated fewer falls, higher reactive stability, and higher vertical limb support (p < 0.05) following gait-slips with functional electrical stimulation compared to those without. This was accompanied by reduced step initiation time and a longer compensatory step (p < 0.05).

CONCLUSION

The application of functional electrical stimulation to paretic quadriceps following gait-slips reduced laboratory fall incidence with enhanced reactive balance outcomes among people with higher stroke-related motor impairment. Our results lay the preliminary groundwork for understanding the instantaneous neuromodulatory effect of functional electrical stimulation in preventing gait-slip falls, future studies could test its therapeutic effect on reactive balance. Clinical registry number: NCT04957355.

Within-subject changes in methylome profile identify individual signatures of early-life adversity, with a potential to predict neuropsychiatric outcome

Background

Adverse early-life experiences (ELA), including poverty, trauma and neglect, affect a majority of the world's children. Whereas the impact of ELA on cognitive and emotional health throughout the lifespan is well-established, it is not clear how distinct types of ELA influence child development, and there are no tools to predict for an individual child their vulnerability or resilience to the consequences of ELAs. Epigenetic markers including DNA-methylation profiles of peripheral cells may encode ELA and provide a predictive outcome marker. However, the rapid dynamic changes in DNA methylation in childhood and the inter-individual variance of the human genome pose barriers to identifying profiles predicting outcomes of ELA exposure. Here, we examined the relation of several dimensions of ELA to changes of DNA methylation, using a longitudinal within-subject design and a high threshold for methylation changes in the hope of mitigating the above challenges.

Methods

We analyzed DNA methylation in buccal swab samples collected twice for each of 110 infants: neonatally and at 12 months. We identified CpGs differentially methylated across time, calculated methylation changes for each child, and determined whether several indicators of ELA associated with changes of DNA methylation for individual infants. We then correlated select dimensions of ELA with methylation changes as well as with measures of executive function at age 5 years. We examined for sex differences, and derived a sex-dependent 'impact score' based on sites that most contributed to the methylation changes.

Findings

Setting a high threshold for methylation changes, we discovered that changes in methylation between two samples of an individual child reflected age-related trends towards augmented methylation, and also correlated with executive function years later. Among the tested factors and ELA dimensions, including income to needs ratios, maternal sensitivity, body mass index and sex, unpredictability of parental and household signals was the strongest predictor of executive function. In girls, an interaction was observed between a measure of high early-life unpredictability and methylation changes, in presaging executive function.

Interpretation

These findings establish longitudinal, within-subject changes in methylation profiles as a signature of some types of ELA in an individual child. Notably, such changes are detectable beyond the age-associated DNA methylation dynamics. Future studies are required to determine if the methylation profile changes identified here provide a predictive marker of vulnerabilities to poorer cognitive and emotional outcomes.