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Perturbation training

From EverybodyWiki Bios & Wiki



Postural reflexes, which are automatic reflexes in our body, are recruited immediately after a sudden external force to maintain their posture and balance-state of stability. It is change-in-support reactions, which involve rapid stepping and grasping movements, that are ultimately essential to prevent falling[1] Reactive stepping is characterized by: 1) extremely rapid onset and movement speed 2) amplitude and trajectory scaled to the degree of instability and 3) ability to accommodate environmental circumstances[2][3] Perturbation Training is a mode of intervention by inducing postural perturbations, either given in stance or gait[4] to elicit recovery response when the individual experiences a sudden loss of balance, eventually focused to prevent fall. Training is given to specifically improve reactive balance control. Perturbation training is performed on an unstable or moving surface to improve with the muscle and joint kinematics to prevent injuries,[5][6] gait, and postural stability.The novelty of perturbation training is that it focuses on speed of processing and execution of limb movements, as well as rapid re-stabilization. This differs from ‘traditional’ balance training programs using voluntary movements. This training is specific to the demands of balance recovery reactions to prevent a fall following a ‘real life’ loss of balance.

Risk Factors of falls[edit]

Various kinds of individuals of different ages and conditions are at a constant risk of falling.

Healthy Young Individuals[edit]

Most common cause of falls in healthy adults is due to accidents. It may be by slipping or tripping from stable surfaces or stairs, improper footwear, dark surroundings, uneven ground, lack of exercise. Studies suggest that women are more prone to falling than men in all age groups.[7] The most common injuries in the young population due to falls occur at the wrist/hand, knees and ankles.

Older Adults[edit]

Studies have shown that old adults above the age of 65 years are more prone to falls than young healthy adults,[8] which makes them highly susceptible to falls.[9] The most falls in older adults is due to:.[10]

  • Gait Deviations - These are the main changes that occur in the gait patterns of older adults which may contribute to incidence of falls. There may be 10-20% reduction in gait velocity and reduction in stride length, increase in stance width and double support phase, and Bent posture.[11][12][13] Studies show that a wider stride does not necessarily increase stability but instead seems to predict an increased likelihood of experiencing falls.[14]
  • Accidents/Environmental factors– fall may be from stable or unstable surfaces - slipping or tripping on wet surface or ice, from stairs or rugs, and/or due improper footwear.
  • Balance disorders – vertigo, Syncope, Unsteadiness
  • Visual, sensory, motor and cognitive impairment - affected reflexes
  • Medications and alcohol consumption - Taking medications for a long time make you feel dizzy, confused, and slow. Alcohol consumption causes delay in reflexes and hampers balance.
  • Acute and Chronic infections
  • Dehydration

Stroke[edit]

High fall rates in individuals with stroke are reported. Approximately 30% fall at least once a year and 15% fall twice or more.[15] Risk factors for falls in stroke survivor’s are-.[16]

  • Gait Deviations - Disturbance of gait is a common problem post stroke and common contributor of falls and predicts continuing functional decline. Velocity, cadence, stride time, stride length, and temporal symmetry index were reduced and resulted in significant gait deterioration.[17] Reduced propulsion at push-off, decreased leg flexion during the swing phase, reduced stability during the stance phase, and reduced automaticity of walking[18]
  • reduced muscle tone and weakness
  • side effects of drugs (hypoglycemic, antihypertensive, neuroleptic drugs)
  • hypoglycemia
  • hypotension
  • communication disorders
  • hemianopia
  • visuospatial agnosia.

Parkinson's Disease[edit]

Most people with Parkinson’s disease (PD) fall and many experience recurrent falls.[19] A study reported that over 50% of persons with PD fell recurrently.[20] Direct and indirect causes of falls in Patients with Parkinson's Disease:[21]

  • Gait Deviations - Decreased gait velocity and stride length due to Hypokinetic movement, Decreased cadence due to Bradykinetic movements. Increased double-limb support.[22] [17] They also exhibit Flat foot strike.
  • Sudden falls - These are sudden unpredictable falls.
  • Freezing and festination episodes
  • Postural instability
  • Intensified dyskinesia
  • Autonomic system disorders - orthostatic hypotension, neurocardiogenic syncope, postural orthostatic tachycardia syndrome
  • Neurological and sensory disturbances - muscle weakness of lower limbs, deep sensibility impairment, epileptic seizure, cognitive impairment, visual impairment, balance impairment
  • Cardiovascular disease
  • Drugs - Levodopa induced dyskinesia

Multiple Sclerosis[edit]

Evidence show that there is high prevalence of falls among people with Multiple Sclerosis, approximately 50% reporting a fall in the past 6 months.[23] About 30% of those individuals report falling multiple times.

  • Gait Deviations – Gait variability is elevated in individuals with MS.[24] Stride length, Cadence, and Velocity decreased. Stance duration and cycle duration increased.[25]
  • Drop foot - may cause the person to stumble on flat surfaces
  • Ataxia - loss of motor skills. Vestibular ataxia results in loss of balance. Symptoms exacerbated when eyes closed and base of support reduced.
  • Reduced proprioception – no sense of body position and surrounding
  • Improper or reduced use of assistive devices[26]
  • Vision – blurred vision, double vision, loss of peripheral vision
  • Cognitive Changes – Approximately 50% experience difficulty with their cognition over the course of the disease. This affects planning, organizing, problem-solving, and accurately perceive one’s environment. When these problems interfere with walking, it may result in a fall.
  • Neurological medications – causes fatigue,[27] weakness, dizziness.

Dementia[edit]

Studies suggest that Men are twice at the risk of falling than women.[28] Common causes of falls in dementia:

  • Gait Deviations: Slower walking speed, reduced cadence and step length, increased postural flexion, increased double support time[29]
  • Postural instability- gait changes and impaired balance. People with balance deficits are three time more risk of fall than those with normal gait and intact balance
  • Lack of physical exercise
  • Memory impairment
  • Visual impairment
  • Fatigue
  • Medications – psychotropic drugs have effects on balance, reaction time and other sensori-motor functions, orthostatic hypotension and extra pyramidal symptoms

Mechanisms for Postural Adjustments[edit]

Postural control has been defined as the control of the body’s position in space for the purposes of balance and orientation.[30] The postural control system adjusts its goal under different circumstances to maintain a steady, erect stance, maintenance of balance, and conservation of energy.[31] There are various methods to identify the dynamics of human balance control. Perturbed standing and Unperturbed standing are usually studied for quantifying balance control. Center of mass (CoM), center of pressure (CoP) and electromyogram (EMG), joint moments, joint angles and angular velocities measures are commonly used to quantify human balance control. Any external or internal perturbation that changes the projection of the CoM to the limits of the base of support, and the alignment between CoM and CoP, may lead to postural challenge. Balance mechanisms are anticipatory postural adjustments (APA), triggered by feedforward mechanisms prior to the perturbation [32] and Compensatory postural adjustments (CPA) that are initiated by sensory feedback signals.[33] In one of the methods, the sensitivity of the CoP, EMG, CoM to external perturbations or to sensory perturbations have been quantified by estimated frequency response functions (FRFs). By combining sensory and mechanical perturbations and measuring both EMG and CoM responses the dynamics of the musculo-skeletal system and the gain and phase characteristics of reflexive feedback pathways are identified separately.[34]

Perturbation Techniques[edit]

  • Foam Balance activities: The subject stands on soft foam surface and the therapist attempts to perturb patient balance in random fashion.
  • Tiltboard Balance Training - subject stands on a tiltboard and the therapist perturbs the tiltboard in forward and backward and side-to-side directions. Mechanically, the tilt perturbation platform, where the platform can also be moved at different angle, speed, ranges of direction, and amount of tilt.[35]
  • Rollerboard and Platform Perturbations- One paradigm can be to use continuously moving platform, that translates either in anterior-posterior direction or medial-lateral direction and the subject is asked to maintain balance.
  • Revolutionary Technology to Prevent Falls – ActiveStep mobility simulator that prevents falls through dynamic reflex conditioning

Effects of perturbation training[edit]

In Older Adults[edit]

In older adults, balance recovery responses - compensatory stepping and grasping responses are impaired, causing sudden loss of balance leading to falls. Perturbation training aims at improving these balance recovery responses and preventing falls. Studies have found that Perturbation training is effective in improving age-related impairments in stepping and grasping reactions.[36] Gait related changes in elderly provide greater chance of stability during walking due to slow speed and greater base of support, but they also increase the chance of slipping or tripping and falling.[37] Appropriate joint moment generation is required to create sufficient push-off for balance recovery. Age-related changes in muscles, tendons, and neural structures may contribute to slower reactive responses. Interventions involving resistance training along with perturbation training may prove to be beneficial in improving muscle strength and balance recovery. Parameters like Whole body COM displacement - a measure to define the postural control response to external perturbations, Step latency, Step lengths and Number of compensatory steps and Muscle activity via Electromyography(EMG), are measures to define reactive stepping responses and differentiating between fall and no fall.,[38]

Gait training with sudden unexpected perturbations experienced by elderly in experimental settings has shown to have positive impact on physical functions. This paradigm can be thus used as an exercise intervention in reducing rate of falls.[39]

In Stroke[edit]

No exercise intervention has proved to be effective in reducing risk of falls among individuals with stroke[40] There is impairment of stepping responses to sudden perturbations, either with paretic or the non-paretic limb, increasing the rates of falls after stroke.[41] There is evidence of backward loss of balance when either the paretic or the non-paretic limb experience slip like perturbations. .[42] Studies show that the affected or paretic side of the limb has difficulty initiating and executing a successful stepping response and vertical limb support, while perturbed (slipped) on the non-affected (non-paretic) side or the paretic (affected) side of the limb. The COM state stability is computed using COM position and COM velocity with respect to BOS. Compensatory stepping length, trunk angles are other variables that used to define stability and differentiate it with Loss of Balance.[43] A case study observed improved efficacy of stepping reactions and reduced the reliability of assistive devices to control balance and prevent falls.[44] Studies also suggest that cueing will training can facilitate initiation of reactive step from the paretic limb and altered time of fall onset.[45]

In Parkinson's Disease[edit]

Postural instability and freezing of gait usually co-exist, contributing to imbalance and increasing the risk of falls. Perturbed treadmill walking training in older patients with Parkinson’s disease have shown significant amount of gait and balance improvements. Over ground walking speed increased significantly and gait variability reduced. But results show that effects on static postural sway were less pronounced.[46] when gait perturbations induced young Parkinson’s patients, the reactive behavior after repeated perturbations did not improve suggesting more unstable gait patterns and less effective reactive adaptations.[47] In person’s with postural instability, the postural responses and compensatory stepping were smaller, when compared with person’s having freezing gait.[48] Dual tasking increases the risk of falling, suggesting that if the person has postural instability and freezing of gait, they may not be the only factors responsible for fall.[49] Perturbation-based balance training and incremental speed-dependent treadmill training should be a part of rehabilitation program for management of balance and Postural instability in patients with Parkinson’s disease.

ACL reconstruction[edit]

Usually people who have undergone ACL reconstruction, they are asked to return to their daily activities after 6 months of rehabilitation which include strength, agility, and secondary prevention programs. Studies suggest that addition of perturbation training along with other paradigms in rehabilitation do not act as an additional benefit to the rehab programs, but they do improve gait asymmetries of the knee joint.[50][51]

References[edit]

  1. ↑ McIlroy, W. E., & Maki, B. E. (1993). Task constraints on foot movement and the incidence of compensatory stepping following perturbation of upright stance. Brain research, 616(1), 30-38.
  2. ↑ Mansfield, A., Aqui, A., Centen, A., Danells, C. J., DePaul, V. G., Knorr, S., ... & Mochizuki, G. (2015). Perturbation training to promote safe independent mobility post-stroke: study protocol for a randomized controlled trial. BMC neurology, 15(1), 87.
  3. ↑ Mcllroy, W. E., & Maki, B. E. (1996). Influence of destabilization on the temporal characteristics of “volitional” stepping. Journal of motor behavior, 28(1), 28-34.
  4. ↑ Bieryla, K. A., & Madigan, M. L. (2011). Proof of concept for perturbation-based balance training in older adults at a high risk for falls. Archives of physical medicine and rehabilitation, 92(5), 841-843.
  5. ↑ Letafatkar, A., Rajabi, R., Tekamejani, E. E., & Minoonejad, H. (2015). Effects of perturbation training on knee flexion angle and quadriceps to hamstring cocontraction of female athletes with quadriceps dominance deficit: Pre–post intervention study. The Knee, 22(3), 230-236.
  6. ↑ Weltin, E., Gollhofer, A., & Mornieux, G. (2016). Effects of perturbation or plyometric training on core control and knee joint loading in women during lateral movements. Scandinavian journal of medicine & science in sports.
  7. ↑ Talbot, L. A., Musiol, R. J., Witham, E. K., & Metter, E. J. (2005). Falls in young, middle-aged and older community dwelling adults: perceived cause, environmental factors and injury. BMC Public Health, 5(1), 86.
  8. ↑ Gillespie, L. D. (2013). Preventing falls in older people: the story of a Cochrane review. Cochrane Database of Systematic Reviews, 3, ED000053-ED000053.
  9. ↑ Yoshikawa, T. T., Cobbs, E. L., & Brummel-Smith, K. (1993). Ambulatory geriatric care. Mosby Inc.
  10. ↑ O'Loughlin, J. L., Robitaille, Y., Boivin, J. F., & Suissa, S. (1993). Incidence of and risk factors for falls and injurious falls among the community-dwelling elderly. American journal of epidemiology, 137(3), 342-354.
  11. ↑ Winter DA, Patla AE, Frank JS, Walt SE. Biomechanical walking pattern changes in the fit and healthy elderly. Phys Ther. 1990;70(6):340–347.
  12. ↑ Elble RJ, Thomas SS, Higgins C, Colliver J. Stride-dependent changes in gait of older people. J Neurol. 1991;238(1):1–5 .
  13. ↑ Snijders AH, van de Warrenburg BP, Giladi N, Bloem BR. Neurological gait disorders in elderly people: clinical approach and classification. Lancet Neurol. 2007;6(1):63–74.
  14. ↑ Maki, B. E. (1997). Gait changes in older adults: predictors of falls or indicators of fear?. Journal of the American geriatrics society, 45(3), 313-320
  15. ↑ Vivian Weerdesteyn PhD, P. T., de Niet MSc, M., van Duijnhoven MSc, H. J., & Geurts, A. C. (2008). Falls in individuals with stroke. Journal of rehabilitation research and development, 45(8), 1195.
  16. ↑ Tsur, A., & Segal, Z. (2010). Falls in stroke patients: risk factors and risk management. IMAJ-Israel Medical Association Journal, 12(4),216
  17. ↑ Yang, Y. R., Chen, Y. C., Lee, C. S., Cheng, S. J., & Wang, R. Y. (2007). Dual-task-related gait changes in individuals with stroke. Gait & posture, 25(2), 185-190.
  18. ↑ Vivian Weerdesteyn PhD, P. T., de Niet MSc, M., van Duijnhoven MSc, H. J., & Geurts, A. C. (2008). Falls in individuals with stroke. Journal of rehabilitation research and development, 45(8), 1195.
  19. ↑ Allen, N. E., Schwarzel, A. K., & Canning, C. G. (2013). Recurrent falls in Parkinson’s disease: a systematic review. Parkinson’s Disease, 2013.
  20. ↑ Wood, B. H., Bilclough, J. A., Bowron, A., & Walker, R. W. (2002). Incidence and prediction of falls in Parkinson's disease: a prospective multidisciplinary study. Journal of Neurology, Neurosurgery & Psychiatry, 72(6), 721-725.
  21. ↑ C.W. Olanow, R.L. Watts, W.C. Koller An algorithm for the management of Parkinson's disease: treatment guidelines Neurology, 56 (11 Suppl 5) (2001), pp. S1–S88
  22. ↑ McNeely, M. E., Duncan, R. P., & Earhart, G. M. (2012). Medication improves balance and complex gait performance in Parkinson disease. Gait & posture, 36(1), 144-148.
  23. ↑ Finlayson, M. L., Peterson, E. W., & Cho, C. C. (2006). Risk factors for falling among people aged 45 to 90 years with multiple sclerosis. Archives of physical medicine and rehabilitation, 87(9), 1274-1279.
  24. ↑ Socie, M. J., & Sosnoff, J. J. (2013). Gait variability and multiple sclerosis. Multiple sclerosis international, 2013.
  25. ↑ Severini, G., Manca, M., Ferraresi, G., Caniatti, L. M., Cosma, M., Baldasso, F., ... & Basaglia, N. (2017). Evaluation of Clinical Gait Analysis parameters in patients affected by Multiple Sclerosis: Analysis of kinematics. Clinical Biomechanics.
  26. ↑ D. Cattaneo, C. De Nuzzo, T. Fascia, M. Macalli, I. Pisoni, R. Cardini Risks of falls in subjects with multiple sclerosis Arch Phys Med Rehabil, 83 (2002), pp. 864–867
  27. ↑ L.B. Krupp, C. Christodoulou Fatigue in multiple sclerosis Curr Neurol Neurosci Rep, 1 (2001), pp. 294–298
  28. ↑ van Dijk, P. T., Meulenberg, O. G., Van de Sande, H. J., & Habbema, J. D. F. (1993). Falls in dementia patients. The Gerontologist, 33(2), 200-204.
  29. ↑ Shaw, F. E. (2003). Falls in older people with dementia. Geriatr aging, 6(7), 37-40.
  30. ↑ Sousa, A. S., Silva, A., & Tavares, J. M. R. (2012). Biomechanical and neurophysiological mechanisms related to postural control and efficiency of movement: a review. Somatosensory & motor research, 29(4), 131-143.
  31. ↑ Siegelbaum, S. A., & Hudspeth, A. J. (2000). Principles of neural science (Vol. 4, pp. 1227-1246). E. R. Kandel, J. H. Schwartz, & T. M. Jessell (Eds.). New York: McGraw-hill.
  32. ↑ Belen'kii, V. E., Gurfinkel, V. S., & Pal'tsev, E. I. (1967). ON THE CONTROL ELEMENTS OF VOLUNTARY MOVEMENTS. Biofizika.
  33. ↑ Alexandrov, A. V., Frolov, A. A., Horak, F. B., Carlson-Kuhta, P., & Park, S. (2005). Feedback equilibrium control during human standing. Biological cybernetics, 93(5), 309-322.
  34. ↑ van der Kooij, H., van Asseldonk, E., & van der Helm, F. C. (2005). Comparison of different methods to identify and quantify balance control. Journal of Neuroscience Methods, 145(1), 175-203.
  35. ↑ Vestibular Rehabilitation By Susan J Herdman, Richard Clendanie
  36. ↑ Mansfield, A., Peters, A. L., Liu, B. A., Maki, B. E., Horak, F. B., & King, L. A. (2010). Effect of a Perturbation-Based Balance Training Program on Compensatory Stepping and Grasping Reactions in Older Adults: A Randomized Controlled Trial/Invited Commentary/Author Response. Physical therapy, 90(4), 476.
  37. ↑ Pijnappels, M., Reeves, N. D., Maganaris, C. N., & Van Dieen, J. H. (2008). Tripping without falling; lower limb strength, a limitation for balance recovery and a target for training in the elderly. Journal of Electromyography and Kinesiology, 18(2), 188-196.
  38. ↑ Dijkstra, B. W., Horak, F. B., Kamsma, Y., & Peterson, D. S. (2015). Older adults can improve compensatory stepping with repeated postural perturbations. Frontiers in aging neuroscience, 7, 201
  39. ↑ Shimada, H., Obuchi, S., Furuna, T., & Suzuki, T. (2004). New intervention program for preventing falls among frail elderly people: the effects of perturbed walking exercise using a bilateral separated treadmill. American Journal of Physical Medicine & Rehabilitation, 83(7), 493-499.
  40. ↑ Batchelor, F., Hill, K., Mackintosh, S., & Said, C. (2010). What works in falls prevention after stroke?. Stroke, 41(8), 1715-1722.
  41. ↑ Inness, E. L., Mansfield, A., Bayley, M., & McIlroy, W. E. (2016). Reactive Stepping After Stroke: Determinants of Time to Foot Off in the Paretic and Nonparetic Limb. Journal of Neurologic Physical Therapy, 40(3), 196-202.
  42. ↑ Kajrolkar, T., & Bhatt, T. (2016). Falls-risk post-stroke: Examining contributions from paretic versus non paretic limbs to unexpected forward gait slips. Journal of biomechanics, 49(13), 2702-2708.
  43. ↑ Patel, P. J., & Bhatt, T. (2016). Does aging with a cortical lesion increase fall-risk: Examining effect of age versus stroke on intensity modulation of reactive balance responses from slip-like perturbations. Neuroscience, 333, 252-263.
  44. ↑ Mansfield, A., Inness, E. L., Komar, J., Biasin, L., Brunton, K., Lakhani, B., & McIlroy, W. E. (2011). Training rapid stepping responses in an individual with stroke. Physical therapy, 91(6), 958.
  45. ↑ Patel, P., & Bhatt, T. (2015). Modulation of reactive response to slip-like perturbations: effect of explicit cues on paretic versus non-paretic side stepping and fall-risk. Experimental brain research, 233(11), 3047-3058.
  46. ↑ Klamroth, S., Steib, S., Gaßner, H., Goßler, J., Winkler, J., Eskofier, B., ... & Pfeifer, K. (2016). Immediate effects of perturbation treadmill training on gait and postural control in patients with Parkinson’s disease. Gait & Posture, 50, 102-108.
  47. ↑ Catalá, M. M., Woitalla, D., & Arampatzis, A. (2016). Reactive but not predictive locomotor adaptability is impaired in young Parkinson's disease patients. Gait & posture, 48, 177-182.
  48. ↑ Nonnekes, J., de Kam, D., Nijhuis, L. B. O., van Geel, K., Bloem, B. R., Geurts, A., & Weerdesteyn, V. (2015). StartReact effects support different pathophysiological mechanisms underlying freezing of gait and postural instability in Parkinson’s disease. PLoS ONE, 10(3), e0122064.
  49. ↑ Jacobs, J. V., Nutt, J. G., Carlson-Kuhta, P., Allen, R., & Horak, F. B. (2014). Dual tasking during postural stepping responses increases falls but not freezing in people with Parkinson's disease. Parkinsonism & related disorders, 20(7), 779-781.
  50. ↑ Arundale, A. J., Cummer, K., Capin, J. J., Zarzycki, R., & Snyder-Mackler, L. (2017). Report of the Clinical and Functional Primary Outcomes in Men of the ACL-SPORTS Trial: Similar Outcomes in Men Receiving Secondary Prevention With and Without Perturbation Training 1 and 2 Years After ACL Reconstruction. Clinical Orthopaedics and Related Research, 1-12.
  51. ↑ Capin, J. J., Zarzycki, R., Arundale, A., Cummer, K., & Snyder-Mackler, L. (2017). Report of the primary outcomes for gait mechanics in men of the ACL-SPORTS trial: secondary prevention with and without perturbation training does not restore gait symmetry in men 1 or 2 years after ACL reconstruction. Clinical Orthopaedics and Related Research, 1-10.


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