Steven Morrison

Balance Training Reduces Falls Risk in Older Individuals With Type 2 Diabetes

OBJECTIVE This study assessed the effects of balance/strength training on falls risk and posture in older individuals with type 2 diabetes. RESEARCH DESIGN AND METHODS Sixteen individuals with type 2 diabetes and 21 age-matched control subjects (aged 50–75 years) participated. Postural stability and falls risk was assessed before and after a 6-week exercise program. RESULTS Diabetic individuals had significantly higher falls risk score compared with control subjects. The diabetic group also exhibited evidence of mild-to-moderate neuropathy, slower reaction times, and increased postural sway. Following exercise, the diabetic group showed significant improvements in leg strength, faster reaction times, decreased sway, and, consequently, reduced falls risk. CONCLUSIONS Older individuals with diabetes had impaired balance, slower reactions, and consequently a higher falls risk than age-matched control subjects. However, all these variables improved after resistance/balance training. Together these results demonstrate that structured exercise has wide-spread positive effects on physiological function for older individuals with type 2 diabetes.

Postural and resting tremor in the upper limb

OBJECTIVE Tremor from multiple segments of the upper limb was recorded under postural and resting conditions. The aims of this study were to examine the nature of tremor within a single limb segment, intra- and inter-limb co-ordination of tremor, and the influence of cardiac mechanical events on physiological tremor. METHODS Tremor was recorded from eight healthy adult subjects during a postural pointing task where the level of support for the upper limb segments was successively increased. The dynamics of tremor within a single segment were examined using power spectral, ApEn and amplitude analyses. Inter-segment tremor relations were determined using coherence and Cross-correlation analyses. RESULTS Single segment analysis demonstrated that each (unsupported) limb segment contained two major frequency peaks (at 1-4 Hz and 8-12 Hz). Both peaks were still evident in the distal segments when the proximal segments were supported. External support of the more proximal limb segments also resulted in decreased finger tremor, but these changes were not simply additive over segments within a limb or equal across fingers. There were significant relations between adjacent proximal and distal limb segment pairs but no correlations between contralateral limb segments or between heart rate and limb tremor. CONCLUSIONS These findings imply that: the low frequency component (1-4 Hz) of physiological tremor in the hand and finger could not be attributed to passive transmission of oscillations from the upper arm and forearm; and the contribution of proximal segments on tremor in the index finger tremor could not be predicted from mechanical principles alone. The minimization of finger tremor involved compensatory coupling of segments of the upper arm with particular emphasis upon active control of the wrist joint.

Gender Differences in the Variability of Lower Extremity Kinematics During Treadmill Locomotion

The authors examined whether there were gender differences in the variability of basic gait parameters (stride length, stride time) and 3-dimensional (3D) rotations of the hip, knee, and ankle joints during treadmill locomotion of 18 men and 15 women at 4 different gait speeds (walking at 5 km/hr, running at 8, 10, and 12 km/hr). The authors used 2-way analyses of variance to assess the data. No gender differences in the mean values or variability of basic gait parameters were detected. However, the women exhibited lower variability than did the men for 6 individual joint rotations: (a) transverse plane rotations of the ankle joint at 8, 10, and 12 km/hr, (b) transverse plane rotations of the hip and knee joints at 12 km/hr, and (c) sagittal plane rotations of the ankle joint at 12 km/hr. When collapsed across all 3D lower extremity rotations, the data showed that the women had lower variability than did the men at 12 km/hr. Reduced variability may result in more localized mechanical stress on anatomical structures and could therefore be a risk factor for injury in women at high gait speeds. The results also suggested that gender differences in variability may not be consistent across different levels of the motor system.

Inter- and intra-limb coordination in arm tremor

Inter- and intra-limb coordination in arm tremor was examined in adult subjects under vision and no vision conditions using accelerometery techniques. The accelerometer data were analyzed using standard time and frequency domain analyses and the regularity of the acceleration time series was determined using an approximate entropy (Ap En) measure. The data analysis was structured to examine the hypothesis that there is a functional compensatory relation between the motion (tremor) of the limb segments in the arm coordination postural pointing task. The results showed that the level of acceleration increased in a proximal to distal direction within a single arm and was symmetrical across homologous arm segments. The frequency analysis showed the established power spectral profiles for each limb segment in postural tremor tasks, but the finger motion included (beyond the normal 8–12 Hz and 20 Hz tremor) a third slower peak at around 2–3 Hz, due possibly to the reactive forces of the other arm links. There was no effect of vision on the level or frequency patterns of acceleration in the limb segments. The coordination analysis showed that there was no linkage between the arms in either the time or frequency domain in the execution of this postural task. This result would tend to suggest that the neuronal commands underlying normal tremor are not derived from a common central oscillator within the central nervous system but are organized in a parallel fashion. The strength of the coupling of intra-limb coordination varied according to the particular adjacent limb links. There were significant correlations in the time domain and coherence in the frequency domain in the acceleration signals between upper arm and forearm, and between hand and finger. The phase lag of the arm units within each of these respective segment pairs was close to in phase or 0 deg. Significant coherence in the frequency domain was also evident between upper arm and hand motion, with the phase lag between these segments being close to 180 deg out of phase. The Ap En analysis of the acceleration signals revealed that there was more regularity to the upper arm and hand accelerometer signals than the forearm and finger signals. The findings show that the intra-limb coordination of the arm links in a two-limb postural pointing task is effected by a compensatory synergy organized about the action of the wrist and shoulder joints. This compensatory synergy reduces the coordination of the 4 within-limb degrees of freedom (arm links) to, in effect, a single degree of freedom arm control task that is not coupled in organization to the motion of the other limb or the torso. It is proposed that this coordination solution reduces the degrees of freedom independently regulated for realization of the task goal but preserves independent body segment control in critical degrees of freedom for potential adaptation to postural perturbations.

Virtual reality-enhanced partial body weight-supported treadmill training poststroke: feasibility and effectiveness in 6 subjects.

UNLABELLED Walker ML, Ringleb SI, Maihafer GC, Walker R, Crouch JR, Van Lunen B, Morrison S. Virtual reality-enhanced partial body weight-supported treadmill training poststroke: feasibility and effectiveness in 6 subjects. OBJECTIVE To determine whether the use of a low-cost virtual reality (VR) system used in conjunction with partial body weight-supported treadmill training (BWSTT) was feasible and effective in improving the walking and balance abilities of patients poststroke. DESIGN A before-after comparison of a single group with BWSTT intervention. SETTING University research laboratory. PARTICIPANTS A convenience sample of 7 adults who were within 1 year poststroke and who had completed traditional rehabilitation but still exhibited gait deficits. Six participants completed the study. INTERVENTION Twelve treatment sessions of BWSTT with VR. The VR system generated a virtual environment that showed on a television screen in front of the treadmill to give participants the sensation of walking down a city street. A head-mounted position sensor provided postural feedback. MAIN OUTCOME MEASURES Functional Gait Assessment (FGA) score, Berg Balance Scale (BBS) score, and overground walking speed. RESULTS One subject dropped out of the study. All other participants made significant improvements in their ability to walk. FGA scores increased from mean of 13.8 to 18. BBS scores increased from mean of 43.8 to 48.8, although a ceiling effect was seen for this test. Overground walking speed increased from mean of .49m/s to .68m/s. CONCLUSIONS A low-cost VR system combined with BWSTT is feasible for improved gait and balance of patients poststroke.

Age-related differences in postural reaction time and coordination during voluntary sway movements

The elderly are known to exhibit declines in postural control during standing and walking, however little is known about how the elderly react under time-critical and challenging postural situations. The purpose of this study was to examine age-related differences in reaction time (RT) and the pattern of temporal coordination between center of pressure (COP), trunk and head motion during voluntary postural sway movements. Healthy young (n=10; mean=24 years; SD=5 years) and elderly men (n=8; mean=75 years; SD=2 years) stood on a force plate with tri-axial accelerometers attached to the head and lower trunk. Participants were required to generate sway in the anterior-posterior (AP) or medial-lateral (ML) direction in response to an auditory cue during two different testing conditions called Static reaction and Dynamic reaction. Static reactions involved the initiation of voluntary sway in either the AP or ML direction from quiet stance. Dynamic reactions involved an orthogonal switch of voluntary sway between the AP and ML directions. Compared to the young, elderly individuals exhibited slower RT during both Static and Dynamic reaction, and smaller differences in RT and phasing between COP, trunk, and head motion. The results of this study suggest that the elderly adopted more rigid coordination strategies compared to the young when executing a rapid change in direction of whole body motion. The rigid movement strategy of the elderly was presumably generated in an effort to compensate for increased challenge to the maintenance of stability.

Relation between risk of falling and postural sway complexity in diabetes

For older individuals with diabetes, any decline in balance control can be especially problematic since it is often a precursor to an increased risk of falling. This study was designed to evaluate differences in postural motion dynamics and falls risk for older individuals with type 2 diabetes (T2DM) classified as fallers/non-fallers and, to assess what impact exercise has on balance and falls risk. The results demonstrated that the risk of falling is greater for those older individuals with multiple risk factors including diabetes and a previous falls history. The postural motion features of the high-risk individuals (T2DM-fallers) were also different, being characterized by increased variability and complexity, increased AP-ML coupling, less overall COP motion and increased velocity. One suggestion is that these individuals evoked a stiffening strategy during the more challenging postural tasks. Following training, a decline in falls risk was observed for all groups, with this effect being most pronounced for the T2DM-fallers. Interestingly, the COP motion of this group became more similar to controls, exhibiting decreased complexity and variability, and decreased velocity. The reciprocal changes in COP complexity support the broader view that age/disease-related changes in physiological complexity are bi-directional. Overall, these results show that, even for older T2DM individuals at greater risk of falling, targeted interventions can positively enhance their postural dynamics. Further, the finding that the pattern of postural motion variability and complexity was altered highlights that a decline in physiological complexity may not always be negatively associated with aging and/or disease.

Changes in the dynamics of tremor during goal-directed pointing.

For successful performance of activities requiring a fine level of manipulative control and dexterity, precise control over the intrinsic oscillations (tremor) in each segment is essential. However, the question of how individuals control (minimize) their tremor during precise postural movements remains unresolved. The aim of this study was to investigate the changes observed in limb tremor during goal-directed postural pointing tasks. Seven subjects attempted to minimize limb tremor during a pointing task whereby progressively greater levels of accuracy were required. Subjects held a small lightweight laser pointer in their extended hand during all tasks, the goal being to maintain the laser emission within a specified target area. Frequency analysis showed that the tremor profile for the hand and index finger was characterized by two prominent frequency peaks, located between 2-4 and 8-12 Hz. When the accuracy requirement of the task increased, there was a significant increase in the amplitude of the 8-12 Hz peak for all segments. Analysis of the time series component of tremor revealed a similar trend with the root mean square (RMS) and approximate entropy (ApEn) of the finger tremor increasing as the accuracy requirement increased. This same pattern was not seen for hand tremor where a small but systematic decrease in both the tremor RMS and ApEn was observed. Overall, it would appear that subjects attempted to reduce tremor at the finger by exerting greater control over the hand (as evidenced by decreased tremor output and increased regularity in the tremor signal). Unfortunately, the consequence of this strategy was that the tremor in the distal effector actually increased. Changes in the tremor output observed as a result of defining an explicit external goal probably resulted from the enhanced visual information provided by the laser emission. However, it would appear that subjects were not able to utilize this feedback effectively to reduce their tremor during the targeting tasks.

What Are the Relations Between Voluntary Postural Sway Measures and Falls-History Status in Community-Dwelling Older Adults?

OBJECTIVES To determine whether a series of voluntary postural sway tasks could differentiate and accurately identify the falls-history status of older adults, and to examine the relations between voluntary sway measures and falls risk. DESIGN Case-control study. SETTING University biomechanics laboratory. PARTICIPANTS Healthy community-dwelling older adults (N=51) aged 65 to 94 years who were divided into nonfaller (n=36), single faller (n=10), and multiple faller (n=5) groups based on a 12-month history of falls. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Participants underwent a falls-risk assessment using the Physiological Profile Assessment (PPA) and then performed 6 voluntary postural sway tasks. The tasks included maximum static leans, maximum voluntary sway, continuous voluntary sway, rapid initiation of voluntary sway, rapid termination of voluntary sway, and rapid orthogonal switches of voluntary sway between the anterior-posterior and medial-lateral directions. Center of pressure amplitudes and reaction time measures were examined using analysis of covariance, Pearsons correlation, and discriminant function analyses. RESULTS Multiple fallers had increased age; increased falls risk; slower initiation, termination, and orthogonal switch reaction times; and reduced center of pressure amplitude during sway initiation and continuous voluntary sway compared with nonfallers. Few differences were observed between the nonfallers and single fallers. Voluntary sway measures were significantly correlated with each other and with PPA score. Two postural reaction time measures and age identified 80% of multiple fallers and 98% of nonmultiple fallers. Similarly, PPA score and age identified 80% of multiple fallers and 100% of nonmultiple fallers. CONCLUSIONS The slower and less effective balance responses of multiple fallers compared with nonfallers and the comparable sensitivity and specificity of PPA score and reactive voluntary sway measures indicate that postural reaction time is a strong determinant of falls risk.

Interlimb coordination as a function of isometric force output.

In the 2 experiments reported here, the influence of level of force output on interlimb coordination in an isometric force tusk was examined. Healthy adults (N = 8) were required to match a continuous total level of isometric force produced by the output of the two index fingers over a range of force levels (1 % to 80% ot maximum). The results showed that (a) coordination between fingers increased as force level increased; (b) coordination between fingers was less than that of the force output of each finger to the total force, but that difference in relative coordination decreased as target force levels increased; and (c) the regularity of the force output of each finger considered separately was greater than that of the total force. Overall, force level was found to have a small but reliable effect on interlimb coordination within a compensatory action between fingers that reduces task error.